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CASE REPORT
Persistent pusher behavior after a stroke
Taiza E.G. Santos-PontelliI,
Corresponding author
taiza@fmrp.usp.br

Tel.: 55 16 3602-1222
, Octavio M. Pontes-NetoI, Draulio B. de AraujoII, Antonio Carlos SantosI, Joao P. LeiteI
I University of São Paulo School of Medicine at Ribeirão Preto, Department of Neuroscience and Behavior, Ribeirão Preto/SP, Brazil.
II Federal University of Rio Grande do Norte (UFRN), Brain Institute Natal/RN, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Pusher behavior &#40;PB&#41; is a postural control disorder characterized by actively pushing away from the nonparetic side and resisting passive correction with a tendency to fall toward the paralyzed side&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> These patients have no awareness that their active pushing is counterproductive&#44; which precludes the patients from standing without assistance&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">Several studies have already demonstrated that PB can occur in patients with lesions in both hemispheres&#44; and PB is distinct from neglect and anosognosia&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#8211;8</a> The high frequency of the association between PB and neurophysiological deficits might reflect an increased vulnerability of certain regions to stroke-induced injury rather than any direct involvement with the occurrence of PB&#46;<a class="elsevierStyleCrossRefs" href="#bib9">9&#44;10</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Traditionally&#44; PB has only been reported in stroke patients&#59; however&#44; it has also been described under non-stroke conditions&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> Previous imaging studies have suggested the posterolateral thalamus as the brain structure that is typically damaged in pusher patients&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;11</a> Nevertheless&#44; other cortical and subcortical areas&#44; such as the insular cortex and post-central gyrus&#44; have also been highlighted as structures that are potentially involved in the pathophysiology of PB&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;12&#8211;16</a></p><p id="para40" class="elsevierStylePara elsevierViewall">The mechanisms underlying PB have been attributed to vertical perception dysfunction that leads to postural reactive behavior&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;14&#44;17&#8211;19</a> Nevertheless&#44; the true changes in the verticality perception of these patients are still unclear&#46; In this context&#44; Karnath et al&#46; identified five patients with severe PB who experience their body &#40;subjective postural vertical &#91;SPV&#93;&#41; as oriented &#8220;upright&#8221; when it is actually tilted approximately 18&#176; toward the side of the brain lesion and with no subjective visual vertical &#40;SVV&#41; bias&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Johansen et al&#46; also found no SVV bias in 15 PB patients&#46;<a class="elsevierStyleCrossRef" href="#bib20">20</a> In contrast&#44; P&#233;rrenou et al&#46; found SPV&#44; SVV&#44; and subjective haptic vertical &#40;SHV&#41; biases toward the side opposite the brain lesion in six pusher patients&#46;<a class="elsevierStyleCrossRef" href="#bib21">21</a> It is clear that&#44; to state which vertical perception is disturbed in PB patients&#44; the studies&#39; designs require a meticulous methodology&#44; including the analysis of neglect and the influence of haptics on SVV in a large sample of PB patients&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">Until now&#44; PB has only been reported as a temporary and transitory phenomenon with a maximum recovery time of six months&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;22&#8211;24</a> Moreover&#44; it has been suggested that PB does not negatively influence the functional outcomes of rehabilitation&#46;<a class="elsevierStyleCrossRefs" href="#bib10">10&#44;22</a> Nevertheless&#44; those assumptions have primarily emerged from case series of stroke patients admitted to stroke units or followed in rehabilitation centers in developed countries&#46;<a class="elsevierStyleCrossRefs" href="#bib10">10&#44;22&#8211;24</a> Therefore&#44; the actual impact of the disorder on stroke patients in developing countries may be underestimated&#46; Here&#44; we report three cases of stroke patients that had persistent PB with important disabling consequences on their functional outcomes&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE DESCRIPTION</span><p id="para60" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 1&#58;</span> A 77-year-old right-handed male with a history of hypertension was admitted after being found confused and left-hemiparetic with an NIH stroke scale<a class="elsevierStyleCrossRef" href="#bib25">25</a> score of 20&#46; Cranial CT revealed a right-middle cerebral artery ischemic stroke &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1a</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; The PB was identified 10 days after the onset of ictus with a Scale for Contraversive Pushing &#40;SCP&#41;<a class="elsevierStyleCrossRef" href="#bib3">3</a> score of 6&#44; and he was discharged 10 days later&#46; The patient was reevaluated 318 days after the onset of ictus and still presented severe PB &#40;SCP &#61; 6&#41; and a Barthel Index<a class="elsevierStyleCrossRef" href="#bib25">25</a> score of zero&#46; He died because of pneumonia a few weeks after his last reevaluation&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para70" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 2&#58;</span> A 74-year-old right-handed male with a history of alcohol and tobacco abuse was admitted with right hemiparesis and aphasia&#46; A CT scan revealed ischemic strokes in the branches of his left-anterior and middle cerebral arteries &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1b</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; PB was identified nine days after the onset of ictus &#40;SCP &#61; 6&#41;&#46; He was discharged after 20 days&#46; Upon his last reevaluation 763 days after the onset of ictus&#44; severe PB was still present&#44; and he had a Barthel Index score of zero&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Patient 3&#58;</span> A 65-year-old right-handed man with a history of a ruptured right-middle cerebral artery aneurysm treated by surgical clipping in another institution was referred to our outpatient stroke clinic 1&#46;6 years after the onset of ictus when severe PB was identified &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1c</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; Severe PB was still present 729 days after the onset of ictus&#44; and he had a Barthel Index score of 10&#46; &#40;The patient had occasional bladder and bowel incontinence&#46;&#41; He was found dead by his family members a few weeks after his final evaluation&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">In all of the cases&#44; after the identification of PB&#44; the patients were referred to public rehabilitation centers&#44; but their adherence to their rehabilitation programs was neither optimized nor controlled&#46; All of the patients had restricted access to physiotherapy &#40;the mean number of sessions per week was less than 1&#41; and remained lying in bed almost the entire day&#46; Furthermore&#44; upon their final reevaluations&#44; all of the patients were completely dependent on their activities of daily living with a modified Rankin scale score of 5&#44; the strengths of their arms and legs opposite their brain lesions did not change over time&#44; and they had a persistent fear of falling&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para100" class="elsevierStylePara elsevierViewall">This is the first demonstration that PB can persist for more than two years&#44; with disastrous impacts on functional outcomes&#46; Certainly&#44; the factors that negatively influenced the duration of PB were the limited frequency of physiotherapy and the absence of specific strategies for treating PB&#46; In fact&#44; some well-described physiotherapy approaches have been proposed&#44;<a class="elsevierStyleCrossRefs" href="#bib23">23&#44;26&#8211;29</a> but there have been no randomized control trials that have confirmed their effectiveness&#46; Still&#44; there is strong evidence that stroke rehabilitation that is initiated early after onset and sustained across the healthcare continuum significantly reduces the probability of disability within the first year&#46;<a class="elsevierStyleCrossRefs" href="#bib30">30&#44;31</a> Furthermore&#44; the poor socioeconomic conditions of the patients restricted their home care and led to the patients lying in bed almost the entire day&#44; despite their physiotherapeutic recommendations&#46; Thus&#44; the privation of experience in the vertical position after their strokes could have negatively influenced the patients&#39; prognoses&#46; This observation raises the question of whether the duration of PB could be shortened by the simple attitude of remaining in a vertical position for several daylight hours&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">PB has been considered to be a neurological behavior that is not strongly associated with the recovery of motor control in the upper and lower limbs&#46;<a class="elsevierStyleCrossRefs" href="#bib24">24&#44;32</a> Nevertheless&#44; we observed poor concomitant PB recovery and other neurological deficits&#44; which might reflect the maladaptive mechanisms underlying the lack of plasticity&#46; Additional studies will be needed to understand the neuroplastic mechanisms of PB recovery using brain-activation techniques &#40;functional magnetic resonance&#44; single-photon emission computed tomography&#44; positron emission tomography&#44; magnetoencephalography&#44; and event-related potential&#41; and transcranial magnetic stimulation techniques&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Spatial neglect has been identified as a factor that worsens the prognosis of PB&#44;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;10&#44;24</a> and this clinical characteristic was found in two of our patients&#46; Thus&#44; we cannot suggest that the poor recovery observed in our patients could be entirely due to the presence of spatial neglect&#46; Moreover&#44; we were unable to evaluate the perception of verticality&#46; Future studies should explore whether the vertical misperceptions of the pusher patients influence the duration and severity of PB&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">The absence of sitting balance soon after stroke has consistently been shown to predict a poor recovery&#46;<a class="elsevierStyleCrossRef" href="#bib33">33</a> Moreover&#44; predicting the outcome of a stroke is important for triage decisions&#44; prognostic estimates for the family&#44; and the appropriate utilization of resources&#46;<a class="elsevierStyleCrossRef" href="#bib34">34</a> It is noteworthy that while the patients presented PB&#44; all of their daily life activities were compromised&#46; Thus&#44; this study highlights that PB can be much more incapacitating than generally believed&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported&#46;</p> <p class="elsevierStyleNotepara" id="cenpara20">Santos-Pontelli TEG and Pontes-Neto designed and conceived the study&#44; collected&#44; analyzed&#44; interpreted the data&#44; and drafted the manuscript&#46; Araujo DB and Santos AC designed the study&#44; analyzed&#44; interpreted the data and revised the manuscript&#46; Leite JP designed and conceived the study&#44; analyzed and interpreted the data&#44; and revised the manuscript&#46;</p>"
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          "leyenda" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">PB&#44; pusher behavior&#59; NIHSS&#44; National Institutes of Health Stroke Scale&#59;<a class="elsevierStyleCrossRef" href="#bib25">25</a> BI&#44; Barthel Index&#59;<a class="elsevierStyleCrossRef" href="#bib25">25</a> SCP&#44; Scale for Contraversive Pushing&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Spatial neglect was evidenced by typical clinical behavior and positive results on the &#8220;clock-drawing&#8221;&#44; &#8220;cancellation&#8221; and &#8220;line-bisection&#8221; tests&#46;<a class="elsevierStyleCrossRef" href="#bib35">35</a></p>"
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                  \t\t\t\t  " align="center" valign="top" scope="col">SCP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Neglect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Anosognosia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Sensitive deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Muscle strengh Contralesioinal limbs&#47;Ipsilesional limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Hemianopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Aphasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Dysarthria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Previous encephalic lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Barthel Index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top"><span class="elsevierStyleBold">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">318&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Hypoesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&#47;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top"><span class="elsevierStyleBold">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">763&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Hypoesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">1&#47;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">789&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Hypoesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">2&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">The demographic and clinical data of the patients&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:35 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              PM Davies \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "Steps to follow&#58; a guide to the treatment of adult hemiplegia"
                        "fecha" => "1985"
                        "editorial" => "Springer"
                        "editorialLocalizacion" => "New York"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ipsilateral pushing in stroke&#58; incidence&#44; relation to neuropsychological symptoms&#44; and impact on rehabilitation&#46; The Copenhagen Stroke Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => """
                              PM Pedersen \n
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                              """
                            1 => """
                              A Wandel \n
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                              """
                            2 => """
                              HS Jorgensen \n
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                              """
                            3 => """
                              H Nakayama \n
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                              """
                            4 => """
                              HO Raaschou \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              TS Olsen \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/s0003-9993(96)90215-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Phys Med Rehabil"
                        "fecha" => "1996"
                        "volumen" => "77"
                        "paginaInicial" => "25"
                        "paginaFinal" => "28"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8554469"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1016/s0003-9993(96)90215-4"
                      "WWW" => array:1 [
                        "link" => "10&#46;1016&#47;S0003-9993&#40;96&#41;90215-4"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The origin of contraversive pushing&#58; evidence for a second graviceptive system in humans"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              HO Karnath \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Ferber \n
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                              """
                            2 => """
                              J Dichgans \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1212/wnl.55.9.1298"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurology"
                        "fecha" => "2000"
                        "volumen" => "55"
                        "paginaInicial" => "1298"
                        "paginaFinal" => "1304"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11087771"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The neural representation of postural control in humans"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              HO Karnath \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Ferber \n
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                              """
                            2 => """
                              J Dichgans \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1073/pnas.240279997"
                      "Revista" => array:6 [
                        "tituloSerie" => "Proc Natl Acad Sci U S A"
                        "fecha" => "2000"
                        "volumen" => "97"
                        "paginaInicial" => "13931"
                        "paginaFinal" => "13936"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11087818"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1073/pnas.240279997"
                      "WWW" => array:1 [
                        "link" => "10&#46;1073&#47;pnas&#46;240279997"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pusher syndrome in stroke&#58; clinical&#44; neuropsychological&#44; and neurophysiological investigation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              S Premoselli \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              L Cesana \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              C Cerri \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Med Phys"
                        "fecha" => "2001"
                        "volumen" => "37"
                        "paginaInicial" => "143"
                        "paginaFinal" => "151"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "J&#46; Understanding the pusher behavior of some stroke patients with spatial deficit&#58; A pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => """
                              DA P&#233;rrenou \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              B Laassel \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              EM Benaim \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              C Herisson \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              C Pelissier \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Phys Med Rehabil"
                        "fecha" => "2002"
                        "volumen" => "83"
                        "paginaInicial" => "570"
                        "paginaFinal" => "575"
                      ]
                    ]
                    1 => array:1 [
                      "WWW" => array:1 [
                        "link" => "10&#46;1053&#47;apmr&#46;2002&#46;31198"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pusher syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => """
                              RW Bohannon \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Phys Ther"
                        "fecha" => "2004"
                        "volumen" => "84"
                        "paginaInicial" => "580"
                        "paginaFinal" => "1&#59; author reply 2-3"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15161423"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contraversive pushing in non-stroke patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => """
                              TE Santos-Pontelli \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              OM Pontes-Neto \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              JF Colafemina \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              DB de Araujo \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              AC Santos \n
                              \t\t\t\t\t\t\t\t
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos