rTMS Enters a Controlled Trial for Poststroke Pusher Syndrome
Poststroke pusher syndrome remains one of the more difficult rehabilitation problems after stroke. Patients actively resist correction toward upright posture, lean toward the affected side, and often require longer inpatient rehabilitation with a prolonged hospital stay. The behavior is not simply a matter of imbalance or weakness; it reflects a disturbed perception of body orientation that can derail early recovery and make routine mobilization harder for therapists and caregivers alike.
A new randomized controlled protocol is designed to test whether repetitive transcranial magnetic stimulation can help shift that trajectory. The study will compare active rTMS with sham stimulation in patients with poststroke pusher syndrome, asking a direct clinical question: can a non-invasive neuromodulation strategy reduce pushing behavior while also improving motor recovery and mobility?
A Three-Week Blinded Design Built Around Practical Rehabilitation Endpoints
The trial will enroll 34 eligible patients and randomize them to active rTMS or sham rTMS for 3 weeks. Both patients and assessors will be blinded, an important safeguard in a rehabilitation setting where expectation can easily influence bedside performance. The parallel-group structure keeps the comparison straightforward: one arm receives the active neuromodulatory intervention, the other receives a sham procedure that preserves masking while controlling for nonspecific treatment effects.
The primary outcome is pushing behavior. Investigators will measure it with the Burke Lateropulsion Scale and the Scale for Contraversive Pushing, two instruments that capture the core bedside problem in different but complementary ways. In this syndrome, the target is not just posture on a chart; it is the ability to accept vertical alignment, stand safely, and participate in therapy without persistent resistance to correction.
Three weeks is a short treatment window, but in stroke rehabilitation that interval can be clinically decisive. If a therapy reduces lateropulsion early, the downstream effect may be fewer failed transfers, better tolerance of sitting and standing practice, and a more efficient rehabilitation course. For therapists, the distinction between a patient who remains locked into a pushing pattern and one who begins to accept midline has immediate consequences for mobility training.
Why Neuromodulation Is Being Tested in This Syndrome
rTMS has already established a place in stroke rehabilitation guidelines as a non-invasive neuromodulation technique. Its use in this protocol rests on biological plausibility rather than speculation alone. Poststroke pusher syndrome is linked to disrupted cortical processing of body orientation and verticality, and neuromodulation offers a way to influence the networks that support spatial perception, postural control, and motor planning. By altering excitability in targeted cortical circuits, rTMS may help recalibrate the brain’s faulty internal reference for upright posture.
The appeal of this approach lies in its specificity. Conventional rehabilitation works through repetition, cueing, and task practice, but patients with pusher syndrome can remain resistant to those efforts because the underlying perception of vertical is distorted. A neuromodulatory intervention may create a more receptive neurophysiologic state in which standard rehabilitation can work better. In that sense, rTMS is not intended to replace therapy; it is being studied as a potential amplifier of it.
The protocol also reflects an important safety question. Stroke survivors are often medically complex, and any adjunctive brain stimulation strategy must be evaluated not only for efficacy but also for tolerability. The study includes adverse events as a secondary outcome, which is essential for any intervention that may be brought into routine rehabilitation practice if the signal proves favorable.
Mobility and Motor Recovery Will Be Measured Alongside Pushing Behavior
Secondary outcomes extend beyond the pushing phenotype itself. Motor recovery will be assessed with the Fugl-Meyer Assessment Scale motor domain, and mobility will be measured with the Modified Rivermead Mobility Index. Those choices matter because a treatment that changes posture without improving movement would have limited practical value, and a mobility gain without an effect on lateropulsion would leave the core syndrome untouched.
The study schedule includes assessments at baseline and then at 1 week, 2 weeks, and 3 weeks after intervention. Serial measurement gives the trial a way to track whether any effect emerges early, accumulates over time, or remains absent despite repeated sessions. Repeated-measures analysis of variance will be used for the statistical analysis, with significance set at 0.05.
A brief study window does not diminish the clinical relevance of the endpoints. In stroke care, small changes in postural control can unlock larger gains in participation, because a patient who can sit, stand, and transfer with less resistance is far more reachable for therapy. The rehabilitation unit is often where physiology becomes logistics, and pushing behavior can turn a manageable neurological deficit into a prolonged barrier to discharge.
Safety, Ethics, and the Limits of a Protocol-Stage Study
The protocol has already received approval from the Biomedical Ethics Committee of West China Hospital, Sichuan University on 23 March 2022, and the trial is registered in the Chinese Clinical Trial Registry. Those details establish the study’s formal footing, but they do not answer the central clinical question yet. At this stage, the project is still a protocol, so no efficacy or safety outcomes are available.
That limitation is important. The planned sample size is small, the intervention period is brief, and the findings will need careful interpretation even if the results are positive. Rehabilitation trials frequently face variability in stroke severity, lesion location, and baseline functional status, any of which can shape response to therapy. A modestly sized controlled trial can still be valuable, but only if the data are read as an early test of feasibility and signal rather than a final verdict.
The real value of this protocol lies in how directly it addresses an unmet need. Patients with pusher syndrome often progress more slowly than other stroke survivors because their postural perception resists normal correction. If rTMS can reduce that pushing behavior and improve mobility in a blinded controlled setting, it would open a path toward a more targeted rehabilitation strategy for a syndrome that has long been managed with persistence rather than precision. If the treatment is safe but ineffective, the field will still have gained a clearer boundary around where neuromodulation does and does not help in stroke recovery.