Camptocormia induced by atypical antipsychotics and resolved by electroconvulsive therapy

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.

Postural disorders in Parkinson’s disease: clinical characteristics, frequency, pathophysiology and management

SUMMARY Postural disorders are frequently observed in Parkinson’s disease patients and significantly affect patients’ quality of life. They may develop because of increased muscle tonus, which results in shortened muscle fibers and induces contracted postures and subsequent changes in muscles, connective tissue, bones and peripheral nerves. Enhanced muscle tonus may induce forward and/or lateral flexion of the spine. Abnormal postures usually occur in the middle or later stages of the disease, and are often reversible in the supine position. Forward flexion, lateral flexion and, less frequently, antecollis are the common axial postural disorders in Parkinson’s disease patients. While antiparkinsonian drugs may improve these symptoms, they may also induce or worsen them. As postural disorders become irreversible after the development of secondary changes, such as muscle atrophy and bone fracture, physicians should recognize postural disorders at early stages.

Reversal of head drop after discontinuation of olanzapine in a DLB patient

We present a 72-year-oldpatient with probable diffuse Lewy body disease and visual hallucinations, who developed subacute reversible "dropped head syndrome" and parkinsonian signs after the introduction of olanzapine at a total daily dose of 10 mg. One week after olanzapine was withdrawn, the patient's posture started to improve. Further improvement was achieved after dopaminergic substitution. Clinical and electrophysiological observations might indicate neck extensor myopathy due to axial rigidity or focal neck dystonia, induced by dopamine receptor blockade.

Unusual case of camptocormia triggered by lumbar-disc herniation

A 21-year-old male patient with low back pain and marked forward bending was presented. The exaggerated lumbar flexion was preventing him to stand in erect posture but disappeared while lying. The symptoms had begun after he had lifted a heavy object. Straight-leg-raising test could not be performed properly because of the exaggerated pain. The light-touch sense was decreased on L5 and S1 dermatomes. There was no loss of muscle strength. The deep-tendon reflexes were normal. Plain graph showed mild narrowing in the L4-5 and L5-S1 intervertebral spaces. Lumbar magnetic resonance imaging revealed disc protrusions in L4-5 and L5-S1 levels. During his stay in the department, the patient was given tizanidine and tramadol, and physical therapy was performed. A paravertebral intramuscular injection with lidocaine was applied. Moreover, the patient was referred to psychiatrist for evaluation regarding his medical history of conversive seizures and possible efforts for secondary gain. No response was obtained from all the treatments. The final diagnosis was camptocormia triggered by lumbar-disc herniation. He was applied supportive psychotherapy, psychoeducation regarding secondary gain, strong suggestions to improve posture, positive reinforcement, and behavioral therapy. His postural abnormality resolved and disappeared completely with mild pain.