Camptocormia associated with focal myositis in multiple-system atrophy

Predictors and Pathophysiology of Axial Postural Abnormalities in Parkinsonism: A Scoping Review

Background

Postural abnormalities involving the trunk are referred to as axial postural abnormalities and can be observed in over 20% of patients with Parkinson's disease (PD) and in atypical parkinsonism. These symptoms are highly disabling and frequently associated with back pain and a worse quality of life in PD. Despite their frequency, little is known about the pathophysiology of these symptoms and scant data are reported about their clinical predictors, making it difficult to prompt prevention strategies.

Objectives

We conducted a scoping literature review of clinical predictors and pathophysiology of axial postural abnormalities in patients with parkinsonism to identify key concepts, theories and evidence on this topic.

Methods

We applied a systematic approach to identify studies, appraise quality of evidence, summarize main findings, and highlight knowledge gaps.

Results

Ninety-two articles were reviewed: 25% reported on clinical predictors and 75% on pathophysiology. Most studies identified advanced disease stage and greater motor symptoms severity as independent clinical predictors in both PD and multiple system atrophy. Discrepant pathophysiology data suggested different potential central and peripheral pathogenic mechanisms.

Conclusions

The recognition of clinical predictors and pathophysiology of axial postural abnormalities in parkinsonism is far from being elucidated due to literature bias, encompassing different inclusion criteria and measurement tools and heterogeneity of patient samples. Most studies identified advanced disease stage and higher burden of motor symptoms as possible clinical predictors. Pathophysiology data point toward many different (possibly non-mutually exclusive) mechanisms, including dystonia, rigidity, proprioceptive and vestibular impairment, and higher cognitive deficits.

Surgical management of camptocormia in Parkinson's disease: systematic review and meta-analysis

OBJECTIVE

Camptocormia is a potentially debilitating condition in the progression of Parkinson's disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia.

METHODS

PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis.

RESULTS

The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15).

CONCLUSIONS

Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.

Dropped head syndrome due to neuromuscular disorders: Clinical manifestation and evaluation

In this article, we discuss the clinical approach to patients with dropped head syndrome and identify the various neuromuscular causes of dropped head syndrome including muscle, neuromuscular junction, peripheral nerve and motor neuron etiologies. We aim to increase awareness of recognition the entity of dropped head syndrome and factors that may predict response to immunomodulating therapy in dropped head syndrome.

Exploring bedside clinical features of parkinsonism: A focus on differential diagnosis

The proper diagnosis of parkinsonian disorders usually involves three steps: identifying core features of parkinsonism; excluding other causes; and collating supportive evidence based on clinical signs or investigations. While the recognition of cardinal parkinsonian features is usually straightforward, the appreciation of clinical features suggestive of specific parkinsonian disorders can be challenging, and often requires greater experience and skills. In this review, we outline the clinical features that are relevant to the differential diagnosis of common neurodegenerative parkinsonian disorders, including Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration. We aim to make this process relatable to clinicians-in-practice, therefore, have categorised the list of clinical features into groups according to the typical sequence on how clinicians would elicit them during the examination, starting with observation of facial expression and clinical signs of the face, spotting eye movement abnormalities, examination of tremors and jerky limb movements, and finally, examination of posture and gait dysfunction. This review is not intended to be comprehensive. Rather, we have focused on the most common clinical signs that are potentially key to making the correct diagnosis and those that do not require special skills or training for interpretation. Evidence is also provided, where available, such as diagnostic criteria, consensus statements, clinicopathological studies or large multi-centre registries. Pitfalls are also discussed when relevant to the diagnosis. While no clinical signs are pathognomonic for certain parkinsonian disorders, certain clinical clues may assist in narrowing a differential diagnosis and tailoring focused investigations for the individual patient.

Pathophysiological Concepts and Treatment of Camptocormia

Camptocormia is a disabling pathological, non-fixed, forward bending of the trunk. The clinical definition using only the bending angle is insufficient; it should include the subjectively perceived inability to stand upright, occurrence of back pain, typical individual complaints, and need for walking aids and compensatory signs (e.g. back-swept wing sign). Due to the heterogeneous etiologies of camptocormia a broad diagnostic approach is necessary. Camptocormia is most frequently encountered in movement disorders (PD and dystonia) and muscles diseases (myositis and myopathy, mainly facio-scapulo-humeral muscular dystrophy (FSHD)). The main diagnostic aim is to discover the etiology by looking for signs of the underlying disease in the neurological examination, EMG, muscle MRI and possibly biopsy. PD and probably myositic camptocormia can be divided into an acute and a chronic stage according to the duration of camptocormia and the findings in the short time inversion recovery (STIR) and T1 sequences of paravertebral muscle MRI. There is no established treatment of camptocormia resulting from any etiology. Case series suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN-DBS) is effective in the acute but not the chronic stage of PD camptocormia. In chronic stages with degenerated muscles, treatment options are limited to orthoses, walking aids, physiotherapy and pain therapy. In acute myositic camptocormia an escalation strategy with different immunosuppressive drugs is recommended. In dystonic camptocormia, as in dystonia in general, case reports have shown botulinum toxin and DBS of the globus pallidus internus (GPi-DBS) to be effective. Camptocormia in connection with primary myopathies should be treated according to the underlying illness.

Camptocormia in Parkinson's disease: definition, epidemiology, pathogenesis and treatment modalities

Camptocormia is an axial postural deformity characterised by abnormal thoracolumbar spinal flexion. The symptom usually presents while standing, walking or exercising and is alleviated while sitting, lying in a recumbent position, standing against a wall or using walking support. There is no consensus on the degree of thoracolumbar flexion to define camptocormia. However, most authors usually use an arbitrary number of at least 45° flexion of the thoracolumbar spine when the individual is standing or walking. Aetiologies of camptocormia are heterogeneous, and Parkinson's disease (PD) is one of its many causes. The prevalence of camptocormia in PD ranges from 3% to 18%. Central and peripheral mechanisms might both contribute to its pathogenesis. Although there is no established consensus for treatment of camptocormia in PD, there are non-pharmacological, pharmacological and surgical approaches that can be used.

Current Concepts in the Treatment of Multiple System Atrophy

MSA is a progressive neurodegenerative disorder characterized by autonomic failure and a variable combination of poor levodopa-responsive parkinsonism and cerebellar ataxia (CA). Current therapeutic management is based on symptomatic treatment. Almost one third of MSA patients may benefit from l-dopa for the symptomatic treatment of parkinsonism, whereas physiotherapy remains the best therapeutic option for CA. Only midodrine and droxidopa were found to be efficient for neurogenic hypotension in double-blind, controlled studies, whereas other symptoms of autonomic failure may be managed with off-label treatments. To date, no curative treatment is available for MSA. Recent results of neuroprotective and -restorative trials have provided some hope for future advances. Considerations for future clinical trials are also discussed in this review.

Sagittal spinopelvic malalignment in Parkinson disease: prevalence and associations with disease severity

STUDY DESIGN

Prospective study.

OBJECTIVE

Our objectives were to evaluate the prevalence of sagittal spinopelvic malalignment in a consecutive series of patients with Parkinson disease (PD) and to identify factors associated with sagittal spinopelvic deformity in this population.

SUMMARY OF BACKGROUND DATA

PD is a degenerative neurological condition characterized by tremor, rigidity, bradykinesia, and loss of postural reflexes. The prevalence of spinal deformity in PD is higher than that of age-matched adults without PD.

METHODS

This study was a prospective assessment of consecutive patients with PD presenting to a neurology clinic during 12 months. Inclusion criteria included age more than 21 years and diagnosis of PD. Age- and sex-matched control group was selected from patients with cervical spondylosis. Clinical and demographic factors were collected including Unified Parkinson Disease Rating Scale score and Hoehn and Yahr stage. Full-length standing spine radiographs were assessed. Patients were grouped into either low C7 sagittal vertical axis (SVA) (<5 cm) or high C7 SVA (≥5 cm) and into matched (≤10°) or mismatched (>10°) pelvic incidence (PI)-lumbar lordosis.

RESULTS

Eighty-nine patients met criteria (41 males/48 females), including 52 with low C7 SVA and 37 with high C7 SVA. Significantly higher prevalence of high C7 SVA was found in PD (41.6 vs. 16.8%; P < 0.001). The high C7 SVA group was significantly older (72.4 vs. 65.1 yr; P < 0.001) and had a higher proportion of females (68% vs. 44%; P = 0.034), greater severity of PD based on Hoehn and Yahr stage (1.89 vs. 1.37; P < 0.001) and Unified Parkinson Disease Rating Scale (30.5 vs. 17.2; P = 0.002. Unified Parkinson Disease Rating Scale significantly correlated with C7 SVA (r = 0.474). Compared with the matched (≤10°) PI-lumbar lordosis group, the mismatch PI-lumbar lordosis group had higher C7 SVA, higher PI, higher pelvic tilt, lower lumbar lordosis, and lower thoracic kyphosis (P ≤ 0.003).

CONCLUSION

Patients with PD have a high prevalence of sagittal spinopelvic malalignment than control group patients. Greater severity of PD is associated with sagittal spinopelvic malalignment.

LEVEL OF EVIDENCE

3.

[Causes of camptocormia]

In this society with an ever increasing number of the elderly there is an increasing number of causes of a bent spine syndrome (camptocormia/dropped head syndrome). The causes include neurological, neuro-orthopedic, rheumatological and psychiatric disorders. Parkinson's disease, dystonia and neuromuscular diseases (motor neuron disease, myositis and muscular dystrophy) with weakness of the axial muscles may result in bent spine syndrome and is often combined with a dropped head. Disc herniation, hypertrophic spondylosis or pseudospondylolisthesis with spinal narrowing may lead to an abnormal flexion of the trunk. Ankylosing spondylitis can produce a disabling bent spine syndrome. Camptocormia may also be mimicked by osteoporotic fractures of the vertebral bones with wedge-shaped vertebrae. In some cases camptocormia is related to a psychogenic disorder.

Myofibrillar disorganization characterizes myopathy of camptocormia in Parkinson's disease

Camptocormia is a highly disabling syndrome that occurs in various diseases but is particularly associated with Parkinson's disease (PD). Although first described nearly 200 years ago, the morphological changes associated with camptocormia are still under debate and the pathophysiology is unknown. We analyzed paraspinal muscle biopsies of 14 PD patients with camptocormia and compared the findings to sex-matched postmortem controls of comparable age to exclude biopsy site-specific changes. Camptocormia in PD showed a consistent lesion pattern composed of myopathic changes with type-1 fiber hypertrophy, loss of type-2 fibers, loss of oxidative enzyme activity, and acid phosphatase reactivity of lesions. Ultrastructurally, myofibrillar disorganization and Z-band streaming up to electron-dense patches/plaques were seen in the lesions. No aberrant protein aggregation, signs of myositis or mitochondriopathy were found, but the mitochondrial content of paraspinal muscles in patients and controls was markedly higher than known from limb biopsies. Additionally, we were able to demonstrate a link between the severity of the clinical syndrome and the degree of the myopathic changes. Because of the consistent lesion pattern, we propose criteria for the diagnosis of camptocormia in PD from muscle biopsies. The morphological changes show obvious parallels to the muscle pathology of experimental tenotomy reported in the 1970s, which depend on an intact innervation and do not occur after interruption of the myotactic reflexes. A dysregulation of the proprioception could be part of the pathogenesis of camptocormia in Parkinson's disease, particularly in view of the clinical symptoms of rigidity and loss of muscle strength.

Multiple system atrophy: current and future approaches to management

Multiple system atrophy (MSA) is a rare neurodegenerative disorder without any effective treatment in slowing or stopping disease progression. It is characterized by poor levodopa responsive Parkinsonism, cerebellar ataxia, pyramidal signs and autonomic failure in any combination. Current therapeutic strategies are primarily based on dopamine replacement and improvement of autonomic failure. However, symptomatic management remains disappointing and no curative treatment is yet available. Recent experimental evidence has confirmed the key role of alpha-synuclein aggregation in the pathogenesis of MSA. Referring to this hypothesis, transgenic and toxic animal models have been developed to assess candidate drugs for MSA. The standardization of diagnosis criteria and assessment procedures will allow large multicentre clinical trials to be conducted. In this article we review the available symptomatic treatment, recent results of studies investigating potential neuroprotective drugs, and future approaches for the management in MSA.

Acute camptocormia induced by olanzapine: a case report

Introduction

Camptocormia refers to an abnormal posture with flexion of the thoraco-lumbar spine which increases during walking and resolves in supine position. This symptom is an increasingly recognized feature of parkinsonian and dystonic disorders, but may also be caused by neuromuscular diseases. There is recent evidence that both central and peripheral mechanisms may be involved in the pathogenesis of camptocormia. We report a case of acute onset of camptocormia, a rare side effect induced by olanzapine, a second-generation atypical anti-psychotic drug with fewer extra-pyramidal side-effects, increasingly used as first line therapy for schizophrenia, delusional disorders and bipolar disorder.

Case presentation

A 73-year-old Caucasian woman with no history of neuromuscular disorder, treated for chronic delusional disorder for the last ten years, received two injections of long-acting haloperidol. She was then referred for fatigue. Physical examination showed a frank parkinsonism without other abnormalities. Routine laboratory tests showed normal results, notably concerning creatine kinase level. Fatigue was attributed to haloperidol which was substituted for olanzapine. Our patient left the hospital after five days without complaint. She was admitted again three days later with acute back pain. Examination showed camptocormia and tenderness in paraspinal muscles. Creatine kinase level was elevated (2986 UI/L). Magnetic resonance imaging showed necrosis and edema in paraspinal muscles. Olanzapine was discontinued. Pain resolved quickly and muscle enzymes were normalized within ten days. Risperidone was later introduced without significant side-effect. The camptocormic posture had disappeared when the patient was seen as an out-patient one year later.

Conclusions

Camptocormia is a heterogeneous syndrome of various causes. We believe that our case illustrates the need to search for paraspinal muscle damage, including drug-induced rhabdomyolysis, in patients presenting with acute-onset bent spine syndrome. Although rare, the occurrence of camptocormia induced by olanzapine must be considered.

Camptocormia as a presentation of generalized inflammatory myopathy

Camptocormia is an abnormal truncal flexion posture that occurs while walking or standing. It is usually caused by various hypokinetic movement disorders such as Parkinson disease and multiple system atrophy. Myopathy or motor neuron disease can also be infrequent causes of camptocormia. Paraspinous muscle biopsy usually reveals focal myositis, regardless of the etiology of camptocormia. We describe the first case of generalized inflammatory myopathy with prominent camptocormia and proximal muscle weakness. Muscle biopsy of the quadriceps confirmed the diagnosis of polymyositis, and the posture showed modest improvement in response to steroid treatment.

Painful camptocormia: the relevance of shaking your patient's hand

Camptocormia is an abnormal posture with marked flexion of thoracolumbar spine that abates in the recumbent position. Camptocormia has been described in various neurological (Parkinsonism), muscular (myopathy), psychogenic or orthopedic disorders. There are several hypotheses that can explain this impaired posture but they are usually related to the concomitant pathologies. We report the first case of a patient with confirmed myotonic dystrophy addressed to our medical center for impaired posture who underwent extensive medical exams and explorations because of a myotonic hand. Axial weakness and muscle atrophy, validated by CT-scan imaging, are discussed independent of the concomitant pathology (Parkinson, myopathy).

Multiple system atrophy

BACKGROUND

It has been almost 4 decades since the descriptions of the 3 parts of multiple system atrophy (MSA) have taken place, characterized clinically by dysautonomia, parkinsonism, and cerebellar dysfunction. The discovery of a distinctive pathologic maker has finally provided the conceptual synthesis of these 3 entities into the universal designation of MSA as a distinct disease process with a complex combination of clinical presentations. Although advances have been made in terms of awareness and knowledge concerning the clinical features and pathophysiology of MSA, it remains challenging for neurologists who treat these patients to differentiate MSA from its mimics as well as providing them with effective treatment.

REVIEW SUMMARY

The aim of this review is to provide an overview of the advances in the knowledge of the disease, to highlight typical features useful for the recognition of its entity, and to enlist different treatment options.

CONCLUSION

Despite the fact that there is still no treatment modality that can alter the disease progression, a number of useful symptomatic treatment measures are available and should be offered to patients to ameliorate the nonmotor features of MSA and even the motor features that may at least transiently respond to treatment.

Camptocormia and Parkinson's disease: MR imaging

Camptocormia is characterized by an excessive anterior flexion of the spine that appears only when standing or walking. The origin of this symptom remains unknown, but recent clinical reports of camptocormia associated with Parkinson's disease (PD) suggest cerebral involvement in the pathogenesis of camptocormia. This study was undertaken to investigate the hypothesis that camptocormia in PD has a central origin. Seventeen PD patients with camptocormia were prospectively enrolled and were compared to 10 matched PD patients without camptocormia and 12 normal controls. The normalized volumes of the brain, striatal nuclei, and the cross-sectional areas of the midbrain and pons were measured on three-dimensional magnetic resonance imaging. Data were correlated with the severity of the symptoms. The normalized axial surface of the midbrain was statistically smaller in PD patients with camptocormia than in normal controls (P = 0.01). The normalized volumetric data were not statistically different in PD patients with camptocormia. There was a significant negative correlation between the severity of camptocormia and the normalized brain volume (P < 0.009; R = -0.649) and sagittal pons area (P < 0.01; R = -0.642). The results suggest that PD with camptocormia may represent a selective form of PD in which a specific neuronal dysfunction possibly occurs within the brainstem.

Botulinum toxin in the treatment of tremors, dystonias, sialorrhea and other symptoms associated with Parkinson's disease

Botulinum toxins are an effective treatment modality for a growing number of neurologic conditions. Although there has been varied interest and success in their use, they have been studied for a variety of conditions associated with Parkinson's disease. Conditions reviewed in this paper include hand and jaw tremor, dystonia, blepharospasm and apraxia of eyelid opening, bruxism, camptocormia, freezing of gait, sialorrhea and constipation. We will make comments when applicable on our unique experience with botulinum toxin in these conditions. Other conditions associated with Parkinson's disease, which will not be reviewed here, but may benefit from botulinum toxin treatment include anterocollis (also known as dropped head syndrome), hyperhidrosis, seborrhea and overactive bladder.

[Camptocormia disclosing Parkinson's disease]

Camptocormia is characterised as an extreme bent-forward posture of the trunk that disappears in the recumbent position. On X-ray, trunk flexion appears without vertebral rotation as in scoliosis. The condition is a well-known complication of Parkinson's disease (PD) at the late stage. The authors present the case of a 77-year-old woman affected by severe camptocormia, which appeared and worsened in less than 6 months and hindered gait. Despite no signs of PD, neuro-imaging (DAT-Scan) showed an L-Dopa transducer decrease in putamens. A few weeks later, bradykinesia appeared and the clinical diagnosis of PD became more obvious. L-Dopa improved bradykinesia but did not change the bent-spine posture. A 1-year follow-up showed no other signs of PD other than bradykinesia, but the camptocormia was unchanged.