Letter to the Editor
Instructions for the Clinical Scale for
Contraversive Pushing (SCP)
To the Editor:
We would like to thank Drs Baccini, Paci, and Rinaldi
(Neurorehabil Neural Repair 2006;20: 468-472) for their
thorough analysis of reliability and validity of our
Clinical Scale for Contraversive Pushing (SCP).1 This
scale may help diagnose and quantify the behavior of
patients with stroke and left or right brain damage who
demonstrate the “pusher syndrome”—a behaviour in
which patients actively push away from the nonhemi-
paretic side, leading to a loss of postural balance.
Without empirical knowledge about appropriate cutoff
scores for the SCP, we tentatively suggested a criterion1
that was based only on our daily clinical experience and
conservative enough to avoid false-positive diagnoses as
long as no empirical data on reliable cutoff scores were
available. We are delighted that Baccini and coworkers
have filled this gap. The authors selected 26 patients who
had a hemiparesis and postural asymmetry. Their
observed cutoff criterion (all 3 SCP variables >0) in this
selected patients group now requires further investiga-
tion to avoid false-positive diagnoses in an unselected
group of stroke patients (ie, those who typically present
to a department of general neurology).
The SCP investigates 3 variables: (1) spontaneous
body posture, (2) the use of the nonparetic extremities
to bring about the pathological lateral tilt of the body
axis, and (3) resistance to passive correction of tilted
posture. Baccini and colleagues rightly mention that in
our original description of the scale, no details were
provided about how to test subjects’ use of the non-
paretic extremities to bring about the pathological lat-
eral tilt (SCP variable B) before grading them. They
speculated that more detailed instructions, with the
explicit definition of the tasks to be used to explore
changes of position, could enhance the scale’s validity as
a diagnostic tool for pusher syndrome. We agree
and would like to complement instruction and task def-
initions for SCP variable B as follows: abduction
and extension of the nonparetic extremities should
DOI: 10.1177/1545968307300702
370 Copyright © 2007 The American Society of Neurorehabilitation
be assessed in 2 steps. With the patient sitting on the
bedside, the examiner first observes whether the
ipsilesional extremities are spontaneously abducted
from the body, searching for contact with the surface
(arm/hand on mattress; leg/foot on floor), and show
activity to achieve extension of the elbow and/or the
knee and hip joints. If so, variable B is given the value 1
for sitting. If abduction and extension of the nonparetic
extremities are not spontaneously performed, the exam-
iner asks the patient to (1) glide the buttocks on the
mattress toward the nonparetic side and/or (2) change
sitting position from bed to wheelchair toward the non-
paretic side. In the latter case, the buttocks are lifted just
enough to pass over the tires of the wheelchair. The
patient then has to master a small swinging movement
of the buttocks to change seats. The examiner observes
whether, in at least 1 of these 2 situations of position
change ((1) or (2) above), the ipsilesional extremities
are abducted from the body and show activity to achieve
extension of the elbow and/or the knee and hip joints. If
so, variable B is given the value 0.5 for sitting. The
examination continues with the patient standing. The
examiner first observes whether the ipsilesional leg is
spontaneously (already when rising from the sitting
position) abducted and extended. If so, variable B is
given the value 1 for standing. If abduction and exten-
sion of the nonparetic leg are not spontaneously per-
formed, the examiner asks the patient to start walking.
The examiner observes whether the patient now
abducts and extends the ipsilesional leg. If so, variable B
is given the value 0.5 for standing.
Sincerely,
Hans-Otto Karnath, MD PhD
Doris Brötz, PT
Center of Neurology, Hertie Insitute for Clinical Brain
Research, University of Tuebingen, Tuebingen, Germany
 Letter to the Editor

REFERENCE
1. Karnath H-O, Ferber S, Dichgans J. The origin of contraversive
pushing: evidence for a second graviceptive system in humans.
Neurology. 2000;55:1298-1304.
Author Response:
We thank Drs Karnath and Brötz for their positive
comments on our study about some psychometric
properties of the Scale for Contraversive Pushing (SCP).
We appreciate their helpful complement of instructions
for the administration and scoring of this scale, which is
currently, in our opinion, the most useful assessment
tool for pusher behavior. We think that this way, the reli-
ability and validity of the scale will be further enhanced.
Recently, an attempt was made to improve the SCP,
introducing some major changes in the scale and pro-
viding detailed instructions for the scoring criteria.1
However, this modified version is so different from the
original SCP that it should rather be considered a com-
pletely different instrument. The authors did not com-
pare the 2 versions of the SCP, so the advantages of
using the modified scale are not clear. Moreover, cutoff
criteria for diagnosing pusher behavior with the new
scale are not clearly defined. We suggest that future
research should also investigate which of the 2 scales is
more sensitive to changes.
Karnath and Brötz rightly pointed out that the valid-
ity of our suggested cutoff criterion should be confirmed
in unselected stroke patients. We quite agree; indeed, we
stressed this need in our article, too. We are currently try-
ing to clear up this issue in a larger and more representa-
tive sample of hemiplegic patients, along with studying
other psychometric features of the SCP.
Marco Baccini, PT
Unit of Geriatric Rehabilitation, “P. Palagi” Hospital,
Florence, Italy
Matteo Paci, PT, MSc
Department of Rehabilitation Medicine, Prato Hospital,
Prato, Italy
Lucio A. Rinaldi, PT
Unit of Gerontology and Geriatric Medicine,
University of Florence,
Florence, Italy
REFERENCE
1. Lagerqvist J, Skargren E. Pusher syndrome: reliability, validity
and sensitivity to change of a classification instrument. Adv
Physiother. 2006;8:154-160.

Neurorehabilitation and Neural Repair 21(4); 2007 371