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Paper text:
this behavior is 
 characterized by a peculiar tendency to use the non - paretic limbs to actively push away from 
 the non - paretic side in the coronal plane .
studies have shown that this behavior can 
 adversely affect the functional outcome1 , 2 .
karnath et al.3 suggested that pb might 
 result from a mismatch between the normal visual vertical perception and the tilted 
 orientation of a subjective body verticality .
however , patients with pb sometimes resist 
 transitive rolling over , suggesting that pb might be caused by not only by vertical 
 mismatch , but also by excessive motor output by the non - paretic limbs and trunk .
the tonic labyrinthine reflex ( tlr ) is 
 one of the postural reflexes , and it facilitates extensor muscle tone in the supine 
 position , and flexor muscle tone in the prone position4 . in particular , the excessive motor output noted in cases of severe 
 pb appears to be caused by abnormal postural reflexes in anti - gravity activities .
therefore , 
 if pb is associated with the tlr , prone positioning might be useful for inhibiting the 
 excessive motor output . in the present study , the hypothesis that pb might reduce if excessive motor output is 
 restrained was tested by inhibiting muscular hyper - activity by placing the non - paretic limbs 
 and trunk in the prone position
the subjects provided their 
 written informed consent to take part in the study prior to its commencement , and the study 
 procedures were performed in accordance with the declaration of helsinki .
a single case study design ( aba design ) was applied to clarify the effects of the 
 relaxation therapy in the prone position .
the aba design consisted of the following 3 
 phases : baseline , intervention , and follow - up .
in addition to conventional therapy for pb , including 
 visual feedback training , sit - to - stand training , and gait training with a knee - ankle - foot 
 orthosis , patients received relaxation therapy in the prone position for 10 minutes a day . 

the relaxation therapy was performed using a treatment table ( pm-213h ; sakai medical corp . , 

this treatment table had an opening for the face and had an adjustable 
 headrest .
therefore , patients could remain in the prone posture comfortably without rotation 
 or extension of the neck or trunk .
the patients were placed in the prone position and then 
 instructed to relax the neck , trunk , and limbs .
moreover , the body was shaken to reduce 
 excessive muscle tone in the extensor muscles and to facilitate awareness of the excessive 
 motor output .
then , feedback was provided on the difference between a relaxed state and 
 excessive motor output . the scale for contraversive pushing ( scp )
was used to assess the severity of pb and the 
 trunk control test ( tct ) to assess truncal balance5 , 
 6 .
the scp has 3 subscales , and the 
 total scp score was determined by summing the scores of the 3 subscales ( maximum score = 6 
 points ) .
patients were considered to have pb if they scored > 0 points on any of the 
 subscales7 , and severe pb was considered 
 if the total score was 6 points .
the tct has 4 items , and the total tct score is determined 
 by summing the scores of the 4 items ( maximum score = 100 points ) .
introspection regarding use of the non - paretic limbs and the subjective 
 vertical body image in transitive vertical sitting were also checked .
these assessments were 
 performed before and after the baseline phase , and after the intervention and follow - up 
 phases by one of the authors , who was not involved in the treatment .
the demographic and clinical characteristics of the patients are presented in table 1table 1.patients demography and characteristicscase no.age ( yrs)gendertime after onset ( d)diagnosislesion areabrsseverity of sensory loss*severity of unilateral spatial neglect*mmse160sm36hputaminal ( 90cc)ii / i / iiseveresevere17270sf20hputaminal ( 21cc)iii / ii / iiimoderatemoderate15370sf15imiddle cerebral artery ( m1 occlusion)ii / i / iimoderatemoderate25brs : brunnstrom recovery stage ; mmse : mini mental state examination ; f : female ; m : 
 male , i : ischemia ; h : intracerebral hemorrhage
received craniotomy for removal of hematoma .. the results of the assessments are presented in table 2table 2.changes in scores and introspectionbefore baselineafter baselineafter interventionafter follow - upscale for contraversive pushingcase 1663.53.5case 2662.51.75case 35.55.52.53.5trunk control testcase 112122424case 212122424case 3001212introspection about usage of non - paretic 
 limbscase 1  i do not push my non - paretic limbs .
  i noticed that i had been pushing excessively.case 2case 3introspection in the sitting posture upright 
 passivelycase 1my body inclines and seems to fall down.their introspection was not changed.case 2case 3 # the three cases had similar introspection .. the scp and tct scores were poor during the baseline phase ; however , these 
 scores improved after the intervention phase , and all the patients could sit independently . 

brs : brunnstrom recovery stage ; mmse : mini mental state examination ; f : female ; m : 
 male , i : ischemia ; h : intracerebral hemorrhage .
the three cases had similar introspection . in introspection regarding usage of the non - paretic limbs , all the patients were unaware of 
 the excessive reaction during the baseline phase . however , their recognitions were accurate 
 after the intervention phase .
the present study found that relaxation therapy in the prone position reduced pb 
 immediately and continuously .
paci et al.8 reported that treatment 
 using visual or auditory feedback resulted in immediate positive effects for a sub - acute 
 stroke patient .
their patient underwent physiotherapy over a 3-week period , and the scp 
 score improved from 4.75 points to 2.75 points .
krewer et al.9 compared the immediate after - effects of 3 different interventions 
 ( 20 minutes per session ) for pb in a cross - over trial .
their results showed that the 
 reduction in pb was significantly greater with machine - supported gait training than with 
 physiotherapy involving visual feedback components .
the immediate benefits were noted only 
 on the burke lateropulsion scale , which can detect smaller changes than the scp .
although many previous studies have attempted to realign deviated vertical perception using 
 visual cues8,9,10 , no study noticed 
 inhibition of excessive motor output with prone positioning .
therefore , our strategy of 
 prone positioning is a novel intervention strategy for patients with severe pb .
the patients 
 could sit independently after the intervention ; however , their inclined subjective vertical 
 body images did not change .
these results suggest that prone positioning influences motor 
 output rather than vertical perception . it is known that stroke patients are likely to have 
 unbalanced interhemispheric inhibitions , such as excessive non - paretic limb activity11 .
therefore , 
 these patients might have had issues with reflexive or involuntary reactions rather than 
 vertical perception in postural control .
therefore , future studies should include 
 examination of muscle tone with a larger number of patients with different pb severities . 

moreover , further studies are needed to investigate the physiological mechanisms of pb 
 reduction in the prone position . in conclusion ,
[ purpose ] pushing behavior is classically described as a disorder of body orientation in 
 the coronal plane . 
 most interventions for pushing behavior have focused on correcting the 
 deviation in vertical perception . however 
 , pushing behavior seems to involve erroneous 
 movements associated with excessive motor output by the non - paretic limbs and trunk . the 
 present study aimed to inhibit muscular hyper - activity by placing the non - paretic limbs 
 and trunk in the prone position . 
 [ subjects and methods ] the subjects of the present study 
 were 3 acute stroke patients with severe pushing behavior . 
 the study consisted of the 
 following 3 phases : baseline , intervention , and follow - up . 
 in addition to conventional 
 therapy , patients received relaxation therapy in the prone position for 10 minutes a day 
 over 2 days . 
 the severity of pushing behavior was assessed using the scale for 
 contraversive pushing , and truncal balance was evaluated using the trunk control test . 
 
 these assessments were performed before and after the baseline phase , and after the 
 intervention and follow - up phases . [ results ] at the baseline phase , 
 both scores were poor . 
 
 both scores improved after the intervention and follow - up phases , and all the patients 
 could sit independently . 
 [ conclusion ] relaxation therapy in the prone position might 
 ameliorate pushing behavior and impaired truncal balance .