Feedback Interventions in Motor Recovery of Lateropulsion after Stroke: A Literature Review and Case Series

Brain Sci. 2024, 14, 682. https://doi.org/10.3390/brainsci14070682 www.mdpi.com/journal/brainsci Review Feedback Interventions in Motor Recovery of Lateropulsion after Stroke: A Literature Review and Case Series Maria Gomez-Risquet 1, Anja Hochsprung 2, Eleonora Magni 1,* and Carlos Luque-Moreno 3,* 1 Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, 41009 Seville, Spain; [email protected] 2 Unidad de Neurología, Hospital Universitario Virgen Macarena, 41009 Seville, Spain; [email protected] 3 Instituto de Biomedicina de Sevilla (IBiS), Departamento de Fisioterapia, Universidad de Sevilla, 41009 Seville, Spain * Correspondence: [email protected] (E.M.); [email protected] (C.L.-M.) Abstract: Lateropulsion is a post-stroke phenomenon marked by an active push of the body across the midline towards the more affected side and/or a resistance of the weight shift towards the less affected side. Within the mechanisms of treatment, feedback systems have been shown to be effective. The aim of the present study was to create a body of knowledge by performing a literature review on the use of feedback mechanisms in the treatment of lateropulsion and to report two cases of lateropulsion patients who had undergone feedback-based treatment. Methods: The review was performed across five different databases (Embase, Medline/PubMed, Scopus, Web of Science, and PEDro) up to February 2024, and haptic feedback intervention was incorporated into the case series (with lateropulsion and ambulation capacity as the main variables). Results: In total, 211 records were identified and 6 studies were included after the review of the literature. The most used feedback modality was visual feedback. In the case series, positive results were observed from the intervention, particularly in the recovery of lateropulsion and balance, as well as in the improvement of gait for one patient. Patients demonstrated good adherence to the intervention protocol without adverse effects. Conclusions: Visual feedback is the most commonly used feedback modality in lateropulsion patients but other mechanisms such as haptic feedback also are feasible and should be taken into account. Larger sample sizes, extended follow-up periods, and the isolation of feedback mechanisms must be established to clarify evidence. Keywords: stroke rehabilitation; postural balance; gait disorders; neurologic; feedback; haptic technology; lateropulsion; pusher syndrome; contraversive pushing; pusher behavior 1. Introduction Stroke is the second cause of death worldwide and one of the main causes of disability [1]. Because of this, this pathology produces a high socio-sanitary cost, with repercussions on health systems as well as on patients’ and families’ lives. In particular, motor sequelae, specifically hemiparesis, stand out for their prevalence as the main cause of disability in these patients [1,2]. Within the cases where hemiparesis occurs, patients develop the so-called pusher syndrome (PS). Among the studies describing the prevalence of this condition, it has been established that 10% of cases with hemiparesis present it, while this percentage increases to 65% when the stroke is severe [3,4]. However, recent research highlights a higher prevalence of this pushing phenomenon regardless of its severity at greater percentages (55.1%) since it is now predominantly known as lateropulsion (and includes cases ranging from mild to severe impairment) [5]. The actual definition of this condition is “the phenomenon of actively pushing the body across the midline toward the more affected side, and/or actively resisting weight shift toward the less affected side”, Citation: Gomez-Risquet, M.; Hochsprung, A.; Magni, E.; Luque-Moreno, C. Feedback Interventions in Motor Recovery of Lateropulsion after Stroke: A Literature Review and Case Series. Brain Sci. 2024, 14, 682. https://doi.org/10.3390/ brainsci14070682 Academic Editors: Christina Danielli Coelho De Morais Faria and Koichi Hiraoka Received: 27 May 2024 Revised: 26 June 2024 Accepted: 4 July 2024 Published: 5 July 2024 Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Brain Sci. 2024, 14, 682 2 of 19 regardless of underlying mechanisms. This aforementioned factor regarding the terminology of this entity must be considered because of the absence of a consensus in the literature [6]. Previously, terms such as “pusher behavior”, “pusher syndrome”, and “contraversive pushing” have been used to define this phenomenon [6,7]. This lack of agreement poses barriers to accurately comparing research findings, agreeing on measurement tools, establishing a consistent rehabilitation approach, understanding the prevalence of the condition, and applying research findings to clinical practice [7]. Although it might be presumed that the passage of time and the recent increase in research on this topic [8] may have favored the creation of a clear definition for this phenomenon, this has not been the case. In fact, in 2021, an expert panel based on the Delphi method began to address various aspects of lateropulsion, including terminological discussion. As a conclusion of the aforementioned report, it seems that the most appropriate term currently to refer to this clinical picture is lateropulsion [7]. Nevertheless, it remains a little-researched phenomenon, with studies with small sample sizes and not very rigorous designs [9]. Last year, Nolan et al. [6] established clinical recommendations for the management of patients with lateropulsion, as there was no evidence of the existence of any previous clinical practice guidelines. Among different interventions for post-stroke patients, feedback-based technology is an interesting and promising approach. It has been considered effective in fundamental processes of patient physiotherapeutic interventions such as gait re-education [10]. Feedback-based mechanisms provide information about the execution of an activity that the individual themself cannot consciously perceive [11]. This information is collected using specific instruments that process it and retransmit it through auditory, tactile, visual, electrical, or vibratory signals, among others [12,13]. In post-stroke patients with lateropulsion, visual feedback seems to be the most used type in physiotherapeutic interventions [14]. Despite this, various other types of feedback, such as auditory feedback, have also shown promising results in stroke patients [15–17]. Similarly, there is another type of feedback information, called haptic feedback. It is related to the transmission of information or experience through the sense of touch [18]. It is established as a way of providing sensory information to patients with sensorimotor disorders, involving neural structures similar to those activated during tasks in physical environments and facilitating motor learning through better sensorimotor integration [19–21]. Haptic feedback can be categorized into kinesthetic cues (which give spatial references to the user) and tactile cues (which include sensations like vibration, pressure, or texture), both of which can be transmitted through specialized devices [18]. This feedback is implemented in upper-limb recovery [22,23] and virtual reality environments [24]. In addition, these kinds of cues as feedback information have been previously used in balance training [25,26], body positioning [27], and gait re-education [18]. One of the ways in which haptic feedback can be provided to patients is through an electrical sensation on the skin; this can be categorized as a tactile stimulus, offering kinesthetic information to improve body control. In fields where feedback approaches are widely implemented (e.g., gait re-educa- tion), disorders of body perception or laterality are generally established as exclusion criteria [16,28,29]. Thus, patients with lateropulsion are excluded from most of the relevant studies on feedback-based therapies. In addition, recent reviews exploring therapeutic approaches for PS or lateropulsion have not established a specific research strategy incorporating feedback as a key component [14,30]. Consequently, our aim is to conduct a more focused examination of the literature and provide updated insights in the field up to the current year 2024, focusing solely on feedback mechanisms to ensure not to contaminate information provided. Our review encompasses an exploration of feedback mechanisms in these patients, supplemented by a case series involving two patients treated with haptic feedback therapy for lateropulsion. Thus, the primary objective of this study is to contribute to the existing knowledge base on feedback techniques in the clinical management of Brain Sci. 2024, 14, 682 3 of 19 lateropulsion. Additionally, we highlight the feasibility of haptic feedback as a potential treatment modality through the presentation of a case series. 2. Materials and Methods 2.1. Research Protocol A literature review has been performed, searching all articles referring to feedbackbased techniques used in the treatment of pushing or lateropulsion patients. Moreover, a case series concerning two patients with lateropulsion and a haptic feedback treatment was performed. The PRISMA 2020 statement was followed in the structure of the review in [31] and the CARE Checklist was used as a framework for the case series, as well as the National Institutes of Health (NIH) quality assessment tool for case-series research [32,33]. 2.2. Search Strategy, Eligibility Criteria, and Data Extraction The review was performed by searching for potentially eligible trials up to February 2024. This was conducted by two independent reviewers (M.G.-R. and E.M.) and an extra reviewer (C.L.-M.) was consulted for consensus as necessary. The search of the studies was performed in five different databases: Medline/PubMed, Scopus, Web of Science, Embase, and PEDro (search strategies available in Table 1). The PICOS criteria [34] included the following: P (Population): post-stroke patients with lateropulsion, PS, pusher behavior, or contraversive pushing; I (Intervention): feedback; C (Comparator): other techniques or no comparison; O (Outcome): measured through specific and validated tests or scales related to the International Classification of Functioning (ICF); S (type of study): clinical trials (controlled and non-controlled, randomized and non-randomized), pilot studies, case reports, and case series. The research strategy included all available records in English and Spanish and the results were filtered to these languages. Exclusion criteria included interventions where feedback was part of robotic mechanisms, as these could mask the real impact of the feedback since these mechanisms are typically very powerful intervention methods. For the selection of articles, we implemented a rigorous three-step procedure. The first step involved thorough database searches and reviews of titles and abstracts. In the second step, articles were excluded based on their title or abstract, with further analysis conducted against predefined inclusion criteria. The third and final step entailed a comprehensive examination of the full text of each eligible article. Table 1. Search strategies for different databases. Databases Search Strategy Embase feedback system AND (lateropulsion OR “pusher syndrome” OR “pusher behavior” OR “contraversive pushing”) Medline/PubMed Web of Science Scopus feedback AND (lateropulsion OR pusher OR “pusher syndrome” OR “pusher behavior” OR “contraversive pushing”) PEDro “Pusher behavior”, “pusher syndrome”, “contraversive pushing”, and “lateropulsion” combined with “feedback” as keywords (simple search) 2.3. Case Series 2.3.1. Patients Included and International Classification of Functioning Diagnosis A series of two cases was carried out in a pre-experimental procedure as a pilot phase of the research protocol. This study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee (CEI) of the Virgen Macarena and Virgen del Rocío University Hospitals (code 2022-03; Seville, Spain). Brain Sci. 2024, 14, 682 4 of 19 A 52-year-old man (case 1) and a 69-year-old woman (case 2) were included in our case study. Both presented lateropulsion after stroke and were admitted to Virgen Macarena’s Hospital in Seville. Baseline characteristics and clinical features of the participants are showed in Table 2. Table 2. Baseline characteristics and clinical features of the case study participants. Case 1 Case 2 Sex Male Female Age 53 69 Type of stroke Hemorrhagic Ischemic Hemisphere affected Left Right Time post stroke (days) 33 6 ICF diagnosis [35] can be used to describe and classify health and health-related conditions and has been highlighted as a necessary tool for providing a holistic and patientcentered approach [36]. Case 1 exhibited marked muscular weakness in the trunk (b7305.2), as well as hemiparesis on the right side of the body. In the right upper limb, there was complete muscular and sensory impairment (b299.4, b7301.4), while in the right lower limb, there was some activity in the hip flexor muscles (b299.4, b7301.3). Lateropulsion was significantly pronounced (b799.3), and there was a lack of coordination in complex voluntary movements (b7602.4). He was unable to perform transfers from a supine state to a sitting state or from sitting to standing (d410.4), although he was able to maintain a sitting posture, at least for short periods of time (d4153.2). He could not maintain standing balance (d4154.4) or walk (d4509.4). There was no pain (b280.0). In terms of functional independence, he was only independent in eating (d550.0), while for other activities (washing, dressing, toileting), he required assistance. He had fecal and urinary continence (b5253.0, b6202.0). There was family support (e310+4). Case 2 presented significant muscular weakness in the trunk (b7305.3), and hemiparesis on the left side of the body. Complete muscular and sensory impairments were observed in the left upper limb (b299.4, b7301.4), and partial impairments in the lower limb of the same side, showing muscle activity in the hip extensors (b299.4, b7301.3). Lateropulsion was very pronounced (b799.4), and there was a lack of coordination in complex voluntary movements (b7602.4). She also was unable to perform transfers from a supine state to a sitting state or from sitting to standing (d410.4), although she could maintain a sitting posture, at least for short periods of time (d4153.2). She could not maintain standing balance (d4154.4) or walk (d4509.4). She experienced pain (b280.3). In terms of functional independence, she was only independent in eating (d550.0), while for other activities (washing, dressing, toileting), she required assistance. She had fecal and urinary continence (b5253.0, b6202.0). Finally, she had family support (e310+4) but faced housing space limitations (e1551.4). 2.3.2. Treatment Approach In the physiotherapeutic approaches to these patients, the Walking Aid ReMoD V5.0 Type 1 (ReMoD UG, Berlin, Germany) was used (Figure 1). This aid comprises motion sensors, signal transmitters, and a control unit integrated into a vest tailored to the patient’s body. The system delivers haptic electrical stimuli when the trunk bends beyond pre-established degrees, providing real-time feedback to the patient. The electrical stimulus is delivered via two electrodes placed at the infraclavicular and supraclavicular points on both shoulders of the patient. The intervention included six physiotherapy sessions within two weeks and extra time to use the vest autonomously (almost three hours a day). The sessions took place between the hospital and the patients’ residences upon discharge. The physiotherapeutic intervention consisted of mobility, postural, and motor control exercises. Exercises to Brain Sci. 2024, 14, 682 5 of 19 improve balance, transfers, and lower-limb strength and gait training were also performed. An approach based on the performance of cognitive tasks in some exercises was used to improve the acquisition of motor patterns. Both patients performed the exercise protocol with the ReMoD device so that they received feedback about their trunk tilt during the session. This allowed better control of the trunk and continuous provision of information about verticality. Figure 1. (A) Walking Aid ReMoD V5.0 Type 1 (vest and device). 1: Connection cables that transmit the signals, and where the electrodes are plugged in (the electrodes are then placed on the patient’s skin to provide stimulation). 2: Sensors integrated in the vest. 3: ReMoD V5.0 Type 1 control unit device, which provides the electrical stimulus (it features multiple buttons for setting and controlling the signal intensity). 4: Pouch for storing the device while it is in use. (B) Case 1 standing autonomously with the ReMoD vest in a session. 2.3.3. Outcome Variables and Evaluation In this study, lateropulsion and ambulation capacity have been established as the main outcome variable. On the other hand, the rest of the dependent outcome variables have been considered secondary. The scales and tools used to measure lateropulsion were the Scale of Contraversive Pushing (SCP) and the Burke Lateropulsion Scale (BLS). The SCP has 3 components: 1, symmetry of spontaneous body posture; 2, use of limbs (legs and arms); and 3, resistance to passive correction of tilted posture. The total SCP score ranges from 0 to 6, with a higher score indicating a more severe presentation of PS [37]. Originally, patients who met at least one point in each component of the SCP were classified as pushers, but other authors have recently sought to broaden these scoring criteria to include patients with milder lateropulsion (with a total SCP score > 0.5 and at least one of the three components of the SCP with a score < 1) [38]. On the other hand, the BLS has five items of pushing behavior that are assessed in different positions (supine, sitting, standing, walking, and during transfers). It achieves a higher score as the resistance increases across the various items (total score from 0 to 17) and the diagnosis of pushing behavior is considered when two or more points are obtained [39]. Both scales have been studied and exhibit good inter- and intra-observer reliability [37,39]. For the measurement of balance, the following scales were used: Firstly, the Postural Assessment Scale for Stroke (PASS) assessed postural control [40]. This scale consists of 12 items that score according to lower or higher levels of functionality, with a total score of 36 points [41]. The Trunk Impairment Scale (TIS) was also used to assess balance and coordination, where the maximum score achievable is 23 (with higher scores indicating greater trunk mobility) [42,43]. Finally, the Performed Oriented Movement Assessment (POMA) assessed stability tasks related to daily activities and gait performance. This has a maximum score of 28 points and determines a person’s fall risk (18 points or lower) [44]. To assess pain, the short form of the McGill Pain Questionnaire (SF-MPQ) was used. In this questionnaire, pain descriptors are categorized into three dimensions (sensory, Brain Sci. 2024, 14, 682 6 of 19 affective, and evaluative) and the overall score is the result of counting the words selected by the patient and their severity [45]. The total score is 45 points, awarded when severe pain is presented in all descriptors [46]. Related to walking capacity, walking 50 m was measured [47,48] (with or without assistance). The Functional Ambulation Category (FAC) was also used to quantify each patient’s ambulation capacity within a 5-point scale (0 = “absolute inability to walk” and 5 = “walking normally for unlimited distances”) [43]. On one hand, the Modified Rankin Scale (MRS) was used to measure the degree of functional independence [49,50]. It has 7 scores (0 corresponds to no deficit and 6 corresponds to death) [50]. The Barthel Index also measured independence: this index consists of 10 items exploring activities of daily living, with a maximum score of 100 meaning maximum independence [51]. On the other hand, the Quality of Life Scale for Stroke (Spanish scale ECVI-38) and the Hospital Anxiety and Depression Scale (HADS) were used in the quality of life and depression assessments. ECVI-38 measures quality of life. This scale comprises 38 items grouped into 8 domains, with a 5-point scale employed for each item (5 points as an extreme condition). The total score is calculated based on the average of the domains, with a maximum of 100% [52]. The HADS assesses depression and anxiety within 14 items. Possible scores for each item range from 0 to 3, and greater symptom severity is evidenced when items exhibit higher values [53]. A total of three assessments were performed on the two participants: a baseline assessment before the start of the intervention (pre-test assessment), a final assessment after the intervention ended (post-test assessment), and a follow-up assessment one month after the intervention. 3. Results 3.1. Selection of Studies for the Review Of a total of 211 articles identified after the screening procedures, only 6 met the inclusion criteria. In Figure 2, the process flow diagram is shown. In Table 3, a summary of the main characteristics of the studies included and their interventions is presented. Figure 2. PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases and registers only [31]. Brain Sci. 2024, 14, 682 7 of 19 Table 3. Summary of the main characteristics of the studies included. Authors (Year) Study Type (n) Age (Years)/TPS Intervention Dose Outcome Measurements Results Nakamura et al. (2023) [54] CR 1 67/ 48 days 3 interventions phases: A: Balance and gait training with VF. B: Exercises focused on SI (loads, closed eyes, etc.) and balance and gait training. FU: balance and gait training without VF or SI 9 sessions (1 h)/12 days. Total of 9 sessions SARA, BBS, mCTSIB (force platform), H-re- flex from soleus, VST excitability, SVV SARA and BBS improvement occurred mainly after phase A. Generally better performance of mCTSIB after phase B and FU. VST excitability did not change on the affected side. SVV did not change significantly throughout the study. Lee et al. (2017) [55] CS 3 61.67/ 2.3 months avg. Routine PT, SPV VF+, and SPV VF−. Alternating treatments with multiple baseline measures 3 sessions (1 h)/week. Total of 18 sessions SCP, PASS, BI SCP-b = 5 Relative to baseline, all interventions showed improvement. BI, SCP, and PASS scores improved after SPV VF− training compared to after SPV VF+ training in a longer intervention stage. Yang et al. (2015) [56] RCT 12 (EG = 7; CG = 5) 60 ± 15.1/5.9 ± 3.65 months Computer-generated VF (via Nintendo Wii balance board) or mirror VF 3 sessions (20 min VF + 20 min PT)/week for 3 weeks. Total of 9 sessions SCP, BBS, FMA, SCP-b = 4.65 ± 1.05 Both interventions were associated with decreased lateropulsion and improvement of balance (significant difference between groups in favor of experimental: p < 0.01 and p < 0.05, respectively). Krewer et al. (2013) [57] RCT (cross-over) 25 (15 pusher and 10 nonpusher) 65.5 ± 9.5/ 7.7 ± 6.9 months GVS, DGO, and PT-VF 1 single session of each type. Total of 3 sessions SCP, BLS, SCP-b = not found No statistically significant difference between interventions according to SCP. BLS results showed significant improvement after DGO compared to after PT-VF (p < 0.05). Other comparisons did not show significant difference. Broetz et al. (2004) [58] CS 8 63 avg./ 4 days avg. VF (exploring surrounding vertical features) 6 sessions (30 min)/week within 26 days approx. Total of 22 sessions approx. SCP, SCP-b = not found Lateropulsion improved significantly after 3 weeks (p < 0.05). At day 24, six patients sufficiently recovered, achieving the sitting position unsupported (p < 0.05). Paci et al. (2004) [59] CR 1 71/ 27 days Bobath concept, specific pushing activities (somatosensory inputs), and AF and VF (line in mirror) 6 sessions (2 h PT twice a day from Monday to Friday and 1 h on Saturdays)/week. Total of 27 sessions SCP, FMA, MA, BI, MAS, SCP-b = 4.75 Immediate effects after feedback but not after somatosensory approach. No maintenance of these effects to the end of treatment. Lateropulsion was reduced only partially. Abbreviations: AF: auditory feedback; avg.: average; BBS: Berg Balance Scale; BI: Barthel Index; BLS: Burke Lateropulsion Scale; CG: control group; CR: case report; CS: case series; DGO: driven gait orthosis (Lokomat); EG: experimental group; FMA: Fugl-Meyer Assessment Scale; FU: follow-up; GVS: galvanic vestibular stimulation; MA: motor assessment (Lindmark’s); MAS: Modified Ashworth Scale; mCTSIB: Modified Clinical Test of Balance; PASS: Postural Assessment Scale for Stroke Patients; PT: physiotherapy; RCT: randomized controlled trial; SARA: Scale for the Assessment and Rating of Ataxia; SCP: Scale of Contraversive Pushing; SCP-b: SCP score at baseline; SI: somatosensory information; SPV: Subjective Postural Vertical; SVV: Subjective Visual Vertical; TPS: time post stroke; VF: visual feedback; VF+: with visual feedback; VF−: without visual feedback; VST: vestibulospinal tract. Brain Sci. 2024, 14, 682 8 of 19 3.2. Results from the Review 3.2.1. Lateropulsion The SCP and BLS were included in five studies [55–59] and one study [57], respectively. Improvement in the SCP was either related to feedback conditions [56,58,59], had no relation to feedback conditions [55], or did not show relevant results compared to other interventions [57]. In the case of the BLS, one study reported improvement [57] 3.2.2. Balance Two studies measured this variable with the Berg Balance Scale (BBS) [54,56]. Visual feedback explained the improvement in BBS scores in one study [54]. In this study, carried out by Yang et al. (2015) [56], both feedback conditions (computer-generated and mirror feedback) showed positive results in this scale, but there was significant improvement in the experimental group. On the other hand, the PASS was also used in one other study to assess balance [55], reporting an increase in outcome scores after feedback training. Additionally, the Modified Clinical Test of Balance (mCTSIB) carried out by Nakamura et al. [54] reported better results after phase B of their intervention design. 3.2.3. Motor Function Two studies measured this variable [56,59] with the Fugl-Meyer Assessment Scale (FMA), showing an improvement in both feedback and no-feedback conditions. Paci et al. [59] also used Lindmark’s assessment to evaluate this outcome and found positive results after intervention. 3.2.4. Functional Independence The Barthel Index gave information related to this variable in two articles [55,59]. Both articles showed an improvement in this outcome. 3.2.5. Other Outcomes The ataxia of one patient was assessed in one study using the Scale for the Assessment and Rating of Ataxia (SARA) [54], presenting positive results. Other variables, such as the excitability of the vestibulospinal tract (VST) or the perception of visual vertical and the imbalance in the vestibular system, were analyzed using GVS and transcutaneous stimulation and the Subjective Visual Vertical (SVV) approach, respectively [54]. Also, the Modified Ashworth Scale (MAS) was used in one study [59], with no relevant results. 3.3. Results from the Case Series The results of the pre-test, post-test, and follow-up assessments are shown in Table 4. During the implementation of the case series, there were no adverse effects in the participants, and they showed very good adherence to treatment. In the pre-test evaluation, the patients had similarities in their SCP, BLS, TIS, and POMA scores. It is notable that the participants differed greatly in the results of the PASS (where patient 1 had a score of almost twice as much as patient 2’s score). In addition, neither of them had the capacity to walk 50 m before the intervention and had equal scores in the FAC. The patients also differed in their SF-MPQ scores (only participant 2 showed pain during the pre-test). The MRS and BI results were also similar, but it is important to note that both patients exhibited differences in their initial scores for the ECVI-38 and HADS. After the intervention, improvements were observed in the SCP and BLS scores for case 1, while case 2 showed only a decrease of one point in her SCP score and did not exhibit improvement on the BLS. There were enhanced scores on the PASS for both participants. Additionally, case 1 demonstrated improvement in his TIS and POMA scores. The TIS score for case 2 also improved, but on the POMA scale, this patient only scored one point more. Regarding ambulation ability, case 1 achieved the ability to walk 50 m Brain Sci. 2024, 14, 682 9 of 19 post intervention, whereas case 2 did not. Nevertheless, the results on the FAC scale for both patients were modest. The SF-MPQ scores for patient 2 showed a reduction of almost half compared to the pre-test assessment. Neither of the patients showed improvement on the MRS following the intervention. In contrast, both cases demonstrated an increase in their BI scores. Finally, while case 1 showed better results on the HADS, case 2 exhibited an increase in her score, indicating higher levels of anxiety and depression. In the follow-up assessments, case 1 had fully recovered from his lateropulsion and case 2 showed an improvement in her SCP score (from 5 points to 2.25). Both patients showed improvement on the PASS and case 1 also experienced good progress in his TIS and POMA scores. Other notable findings included complete pain recovery in case 2, as evidenced by her SF-MPQ scores. These results are based on the increases shown in the scores of the scales, but it is important to note that these scores should always be contextualized according to the maximum score of each assessment instrument. Also, it will be of great interest to pay attention to the internal constructs of each tool. In addition, there are not enough data to support associations in a statistically significant way. Table 4. Synthesis of results from the case series. Results Case 1 Case 2 ICF Variable Scale/Test Pre-Test Post-Test Follow-Up Pre-Test Post-Test Follow-Up Body function (b) Lateropulsion SCP 5.75 1.75 0 5 4 2.25 BLS 11 3 0 10 10 5 Balance PASS 12 20 26 7 12 17 TIS 2 16 17 2 8 8 POMA 0 8 12 0 1 1 Gait 50 M No Yes Yes No No No FAC 0 1 1 0 0 1 Pain SF-MPQ 0 0 0 14 6 0 Activity and Participation (d) Functional independence MRS 5 5 4 5 5 5 BI 30 40 50 35 40 35 Two previous (b, d) and Environmental Factors (e) Quality of live, anxiety, and depression ECVI-38 74.95 49.30 51.04 57.18 45.94 51.64 HADS 22 11 17 9 15 22 Abbreviations: BI: Barthel Index; BLS: Burke Lateropulsion Scale; ECVI-38: Quality of Life Scale for Stroke; FAC: Functional Ambulation Category; HADS: Hospital Anxiety and Depression Scale; ICF: International Classification of Functioning, Disability and Health; MRS: Modified Rankin Scale; PASS: Postural Assessment Scale for Stroke; POMA: Performed Oriented Movement Assessment; SCP: Scale of Contraversive Pushing; SF-MPQ: short form of the McGill Pain Questionnaire; TIS: Trunk Impairment Scale. 4. Discussion 4.1. Discussion Related to the Review After conducting this specific research in the field of feedback interventions for lateropulsion patients, visual feedback emerges as the predominant approach. These results are consistent with previous studies [14], although a more detailed discussion of specific aspects derived from these results is provided below. While the reviewed studies support this mechanism as an intervention, some studies did not prioritize it at the center of their treatment strategy and used visual feedback as a complementary tool. However, others focused more on it, including the use of computer-generated interactive feedback [56], the use of the Subjective Postural Vertical (SPV) approach [55], or Broetz et al.’s intervention (in general terms, their approach focuses on sensory reorientation based on exploring visual surroundings and the correction of postural perception through specific Brain Sci. 2024, 14, 682 16 of 19 11. 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