Clinical patients with hemiparesis sometimes exhibit an uncommon motor behavior, ipsilateral pushing (pushing), in which the patient tends to push the body away from the non-involved side in any position.Davies described this syndrome in 1985 and named it pusher syndrome. This syndrome is not medically recognized and there is a lack of research reported on this topic in the literature. A study done by Pedersen, Wandell and Jorgensen observed that this syndrome was negated by a specific right parietal lobe injury located on the right side, but they found that it was not related to this. The same study also found no significant correlation between ipsilateral nudging and two perceptual deficits, i.e., lateralized neglect and anosognosia, and further research is needed to explore the role of other dysfunction’s in ipsilateral nudging. For example, Pedersen, Wandell, and Jorgensen suggest investigating the role of subcortical sensory pathways and relay stations as well as the effects of exaggerated sensory feedback on the affected side. Injury to any site involved in sensory information processing can cause dysfunction when afferent information is needed to coordinate spatial movements. Posterior parietal infarcts can cause a variety of visual perceptual deficits in addition to lateralized neglect and anosognosia. The hippocampus is also now thought to play a role in spatial orientation, and if this is the case, the results of damage to this area need to be examined. The original description of Pusher’s syndrome was based solely on the observations of interns. The syndrome is most often thought to be associated with left hemiparesis and perceptual deficits (especially left-sided neglect), left visual field deficits with or without ipsilateral hemianopsia, body scheme with body image, and visuospatial deficits. Although the study could not determine whether pusher syndrome exists, ipsilateral nudging does exist. The cause is not certain, but the nudging behavior persists and was found to be present in 10% of the 327 stroke patients studied by Pedersen, Wandell, and Jorgensen. Gait training in patients with ipsilateral nudging is a challenge. During sit-to-stand activities, some patients quickly tilt out of the seat toward the hemiplegic side, and without protection, they will fall. Transfers to the strong side are very difficult because they always tilt from this strong side to the opposite side. Although transferring to the hemiplegic side is easier, it is more dangerous because of the lack of motor control on that side. Assistance in standing is required to prevent falling towards the weakened side. Initially, walking with the aid of an assistive device, such as a hand-held cane on the strong side, is futile because these patients tend to use the cane to push themselves toward the hemiplegic side. They do not seem to be able to actively shift their center of gravity to the healthy side lower extremity. The more assistance given to the patient (to prevent falling toward the hemiplegic side), the more they push toward the assisting person. Gait training is based on the same principles discussed in the Ataxia Gait section. The fact that patients must relearn to adjust their center of gravity above the support surface while standing suggests the need to be conscious of the patient’s loss of balance. Although Pedersen, Wandell, and Jorgensen found no significant correlation between anosognosia and ipsilateral pushover, they suspected an association with limb weakness and visual field deficits only, not with balance disorders. Self-assessment of patients’ center of gravity positioning relative to the support surface still requires in-depth study. The authors observed that these patients were able to learn balance on their own, and this has been confirmed by Pedersen’s study. Interestingly, the data collected by Pedersen, Wandell, and Jorgensen demonstrated that patients with ipsilateral thrusts on admission had a lower Barthel index at discharge than patients without ipsilateral thrusts. In addition, patients with ipsilateral thrusts had significantly longer hospitalization and recovery times. Retraining to maintain balance while walking can indeed be a scary assignment for patients with ipsilateral thrusts. Patients are encouraged to try and are allowed to make mistakes in order to motivate them to be proactive in solving problems that arise. The difficulty of relearning to maintain balance while walking is complicated and variable by changes in sensation, muscle strength, motor control, and postinfarction feedback loops. Visual and tactile influences are the most important. Having the patient walk around a high mat or table can cue the patient where to shift their weight to avoid falls. The use of a balance bar is discouraged, and the patient must learn to use the trunk to make weight shifts to correct imbalances, rather than just grasping the bar to remain upright. Once the patient has mastered trunk control, he or she can begin to move forward by holding onto the crutches. Therapists are discouraged from utilizing hands-on assistance to move the patient. That will only result in the patient tipping into the therapist’s hands. Sometimes lower extremity weakness interferes with the ability of a person with pusher syndrome to learn postural control and weight shifting, and Davies advocates the use of a splint to immobilize the hemiplegic knee in an extended position while the patient performs active weight shifting during functional standing activities. Immobilizing the knee with a splint in this manner will reduce the incidence of pushing while the patient is in the standing position. It has been suggested that increased stability somehow removes the patient’s fear and allows the therapist time to make an accurate assessment of whether the patient can maintain balance. Perhaps it is the restricted freedom of movement that allows the patient to go about focusing on one activity – weight shifting – to achieve functional goals without attention to the unstable knee. At this point, it is simply a matter of considering what reduces the tendency to push and why. Although gait training using therapeutic techniques has been suggested for patients with ipsilateral knee thrusts, there are no controlled studies to confirm its effectiveness, and these studies are based solely on this and other practitioners’ clinical experience.