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Gandolfi M, Artusi CA, Imbalzano G, Camozzi S, Crestani M, Lopiano L, Tinazzi M, Geroin C. Botulinum Toxin for Axial Postural Abnormalities in Parkinson's Disease: A Systematic Review. Toxins (Basel) 2024; 16:228. [PMID: 38787080 PMCID: PMC11125648 DOI: 10.3390/toxins16050228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/23/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Axial postural abnormalities (APAs), characterized by their frequency, disabling nature, and resistance to pharmacological treatments, significantly impact Parkinson's disease and atypical Parkinsonism patients. Despite advancements in diagnosing, assessing, and understanding their pathophysiology, managing these complications remains a significant challenge. Often underestimated by healthcare professionals, these disturbances can exacerbate disability. This systematic review assesses botulinum toxin treatments' effectiveness, alone and with rehabilitation, in addressing APAs in Parkinson's disease, utilizing MEDLINE (PubMed), Web of Science, and SCOPUS databases for source material. Of the 1087 records retrieved, 16 met the selection criteria. Most research has focused on botulinum toxin (BoNT) as the primary treatment for camptocormia and Pisa syndrome, utilizing mostly observational methods. Despite dose and injection site variations, a common strategy was using electromyography-guided injections, occasionally enhanced with ultrasound. Patients with Pisa syndrome notably saw consistent improvements in APAs and pain. However, studies on the combined effects of botulinum toxin and rehabilitation are limited, and antecollis is significantly under-researched. These findings recommend precise BoNT injections into hyperactive muscles in well-selected patients by skilled clinicians, avoiding compensatory muscles, and underscore the necessity of early rehabilitation. Rehabilitation is crucial in a multidisciplinary approach to managing APAs, highlighting the importance of a multidisciplinary team of experts.
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Affiliation(s)
- Marialuisa Gandolfi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (S.C.); (M.C.)
- Neuromotor and Cognitive Rehabilitation Research Centre (CRRNC), University of Verona, 37134 Verona, Italy
- Neurorehabilitation Unit, AOUI Verona, 37134 Verona, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.A.A.); (G.I.); (L.L.)
- SC Neurology 2U, AOU Città della Salute e della Scienza, 10126 Turin, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.A.A.); (G.I.); (L.L.)
- SC Neurology 2U, AOU Città della Salute e della Scienza, 10126 Turin, Italy
| | - Serena Camozzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (S.C.); (M.C.)
| | - Mauro Crestani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (S.C.); (M.C.)
| | - Leonardo Lopiano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.A.A.); (G.I.); (L.L.)
- SC Neurology 2U, AOU Città della Salute e della Scienza, 10126 Turin, Italy
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (S.C.); (M.C.)
| | - Christian Geroin
- Department of Surgery, Dentistry, Paediatrics and Gynecology, University of Verona, 37134 Verona, Italy;
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Ledda C, Panero E, Dimanico U, Parisi M, Gandolfi M, Tinazzi M, Geroin C, Marchet F, Massazza G, Lopiano L, Artusi CA. Longitudinal Assessment of Botulinum Toxin Treatment for Lateral Trunk Flexion and Pisa Syndrome in Parkinson's Disease: Real-life, Long-Term Study. Toxins (Basel) 2023; 15:566. [PMID: 37755992 PMCID: PMC10536312 DOI: 10.3390/toxins15090566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/28/2023] Open
Abstract
Lateral trunk flexion (LTF) and its severe form, called Pisa syndrome (PS), are highly invalidating axial postural abnormalities associated with Parkinson's disease (PD). Management strategies for LTF lack strong scientific evidence. We present a real-life, longitudinal study evaluating long-term efficacy of botulinum toxin (BoNT) injections in axial muscles to reduce LTF and PS in PD. A total of 13 PD patients with LTF > 5° received ultrasound- and electromyography-guided BoNT injections every 4 months. Seven untreated matched PD patients with LTF served as controls and their changes in posture after 18 months were compared with those of seven patients continuing BoNT over 12 months. 53.8% of patients continued the BoNT injections for at least 12 months. Various individual LTF responses were observed. Overall, BoNT-treated patients obtained a not statistically significant improvement of LTF of 17 ± 41% (p = 0.237). In comparison, the seven untreated PD patients suffered a deterioration in LTF over 12 months by 36 ± 45% (p = 0.116), showing a significantly different trajectory of posture change (p = 0.026). In conclusion, repeated BoNT injections in axial muscles showed varying effects in managing PD-associated LTF, suggesting that: (a) a relevant number of patients with LTF can benefit from BoNT; (b) long-term treatment could prevent LTF worsening; (c) an instrumented, personalized approach is important; and (d) there is a need for prospective, long-term studies.
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Affiliation(s)
- Claudia Ledda
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.L.); (L.L.)
- Neurology 2 Unit, AOU Città della Salute e Della Scienza, 10126 Turin, Italy
| | - Elisa Panero
- Physical Medicine and Rehabilitation Unit, Department of Orthopedics, Traumatology and Rehabilitation, University of Turin, 10126 Turin, Italy; (E.P.); (G.M.)
| | - Ugo Dimanico
- Physical Medicine and Rehabilitation Unit, Department of Orthopedics, Traumatology and Rehabilitation, University of Turin, 10126 Turin, Italy; (E.P.); (G.M.)
| | - Mattia Parisi
- Department of Neurology, Ospedale Rivoli, Rivoli, 10098 Turin, Italy;
| | - Marialuisa Gandolfi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy; (M.G.); (M.T.); (C.G.)
- Neuromotor and Cognitive Rehabilitation Research Centre (CRRNC), University of Verona, 37129 Verona, Italy
| | - Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy; (M.G.); (M.T.); (C.G.)
| | - Christian Geroin
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy; (M.G.); (M.T.); (C.G.)
| | - Francesco Marchet
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy;
| | - Giuseppe Massazza
- Physical Medicine and Rehabilitation Unit, Department of Orthopedics, Traumatology and Rehabilitation, University of Turin, 10126 Turin, Italy; (E.P.); (G.M.)
| | - Leonardo Lopiano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.L.); (L.L.)
- Neurology 2 Unit, AOU Città della Salute e Della Scienza, 10126 Turin, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy; (C.L.); (L.L.)
- Neurology 2 Unit, AOU Città della Salute e Della Scienza, 10126 Turin, Italy
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Barth M, Möbius R, Themann P, Güresir E, Matzke C, Winkler D, Grunert R. Functional improvement of patients with Parkinson syndromes using a rehabilitation training software. Front Neurol 2023; 14:1210926. [PMID: 37645604 PMCID: PMC10461806 DOI: 10.3389/fneur.2023.1210926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/10/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Individuals with Parkinsonian disorders often face limited access to specialized physiotherapy and movement training due to staff shortages and increasing disease incidence, resulting in a rapid decline in mobility and feelings of despair. Addressing these challenges requires allocating adequate resources and implementing specialized training programs to ensure comprehensive care and support. Regarding these problems, a computer software was invented that might serve as an additional home-based extension to conventional physiotherapy. Methods The trial took place in a rehabilitation center where every patient received equivalent treatment apart from the training program that was set up to be investigated over 3 weeks. Seventy four Patients were included and randomized between two intervention and one control group. Intervention group 1 (IG1) trained with the computer-based system two times a week while Intervention group 2 (IG2) received five training sessions a week. Using the markerless Microsoft Kinect® camera, participants controlled a digital avatar with their own body movements. UPDRS-III and Clinical measurements were performed before and after the three-week period. Results Patients in all groups improved in UPDRS-III pre and post intervention whereas reduction rates were higher for IG1 (-10.89%) and IG2 (-14.04%) than for CG (-7.74%). Differences between the groups were not significant (value of ps CG/IG1 0.225, CG/IG2 0.347). Growth rates for the arm abduction angle were significantly higher in IG1 (11.6%) and IG2 (9.97%) than in CG (1.87%) (value of ps CG/IG1 0.006 and CG/IG2 0.018), as was the 5-steps-distance (CG 10.86% vs. IG1 24.5% vs. UG2 26.22%, value of ps CG/IG1 0.011 and CG/IG2 0.031). Discussion The study shows the beneficial effects of computer-based training and substantiates the assumption of a similar impact in a home-based setting. The utilized software is feasible for such interventions and meets with the patient's approval. Group dynamics seem to have an additional supporting effect for the aspired objective of improving mobility and should be seen as an essential aspect of video games in therapy.
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Affiliation(s)
- Marcus Barth
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Robert Möbius
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Peter Themann
- Clinic at Tharandter Forest, Department of Neurology and Parkinson, Halsbruecke, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Cornelia Matzke
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Dirk Winkler
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Ronny Grunert
- Department of Neurosurgery, Faculty of Medicine, Leipzig University, Leipzig, Germany
- Department of Medical Engineering, Fraunhofer-Institute for Machine Tools and Forming Technology, Dresden, Germany
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Aldegheri S, Artusi CA, Camozzi S, Di Marco R, Geroin C, Imbalzano G, Lopiano L, Tinazzi M, Bombieri N. Camera- and Viewpoint-Agnostic Evaluation of Axial Postural Abnormalities in People with Parkinson's Disease through Augmented Human Pose Estimation. SENSORS (BASEL, SWITZERLAND) 2023; 23:3193. [PMID: 36991904 PMCID: PMC10058715 DOI: 10.3390/s23063193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/02/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
Axial postural abnormalities (aPA) are common features of Parkinson's disease (PD) and manifest in over 20% of patients during the course of the disease. aPA form a spectrum of functional trunk misalignment, ranging from a typical Parkinsonian stooped posture to progressively greater degrees of spine deviation. Current research has not yet led to a sufficient understanding of pathophysiology and management of aPA in PD, partially due to lack of agreement on validated, user-friendly, automatic tools for measuring and analysing the differences in the degree of aPA, according to patients' therapeutic conditions and tasks. In this context, human pose estimation (HPE) software based on deep learning could be a valid support as it automatically extrapolates spatial coordinates of the human skeleton keypoints from images or videos. Nevertheless, standard HPE platforms have two limitations that prevent their adoption in such a clinical practice. First, standard HPE keypoints are inconsistent with the keypoints needed to assess aPA (degrees and fulcrum). Second, aPA assessment either requires advanced RGB-D sensors or, when based on the processing of RGB images, they are most likely sensitive to the adopted camera and to the scene (e.g., sensor-subject distance, lighting, background-subject clothing contrast). This article presents a software that augments the human skeleton extrapolated by state-of-the-art HPE software from RGB pictures with exact bone points for posture evaluation through computer vision post-processing primitives. This article shows the software robustness and accuracy on the processing of 76 RGB images with different resolutions and sensor-subject distances from 55 PD patients with different degrees of anterior and lateral trunk flexion.
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Affiliation(s)
- Stefano Aldegheri
- Department of Engineering for Innovation Medicine, University of Verona, 37134 Verona, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10124 Turin, Italy
- Neurology 2 Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Serena Camozzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy
| | - Roberto Di Marco
- Department of Engineering for Innovation Medicine, University of Verona, 37134 Verona, Italy
| | - Christian Geroin
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10124 Turin, Italy
- Neurology 2 Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Leonardo Lopiano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10124 Turin, Italy
- Neurology 2 Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences, University of Verona, 37129 Verona, Italy
| | - Nicola Bombieri
- Department of Engineering for Innovation Medicine, University of Verona, 37134 Verona, Italy
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Yoon SY. Update on Parkinson's Disease Rehabilitation. BRAIN & NEUROREHABILITATION 2022; 15:e15. [PMID: 36743207 PMCID: PMC9833476 DOI: 10.12786/bn.2022.15.e15] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/01/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022] Open
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disorder. Although dopaminergic drugs are the mainstay for improving PD symptoms, there are still few effective disease-modifying therapies. With the increasing prevalence of PD and the rapid transition to an aging society, more emphasis needs to be placed on rehabilitation that could slow the disease progression combined with pharmacological therapy. In this review, we present an update on evidence related to rehabilitation programs for motor function, swallowing difficulty, and speech disorders in PD. Aerobic exercise, music therapy, dance, virtual reality, and non-invasive brain stimulation have been shown to improve motor function, and telerehabilitation could also be feasibly applied in PD. Recent studies have shown the effectiveness of expiratory muscle strengthening exercises and Lee Silverman Voice Treatment for swallowing difficulty and speech disorders, respectively. Although many rehabilitation programs have been tried, the evidence is still limited. Well-designed future randomized controlled trials with large numbers of participants are needed to establish evidence for rehabilitation in PD.
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Affiliation(s)
- Seo Yeon Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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Zak M, Sikorski T, Wasik M, Krupnik S, Andrychowski J, Brola W. Pisa syndrome: Pathophysiology, physical rehabilitation and falls risk. NeuroRehabilitation 2021; 49:363-373. [PMID: 34542040 DOI: 10.3233/nre-210167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pisa syndrome (PS) is a postural disorder characterised by lateral flexion of the spine (> 10°), predisposing the affected individuals to falls, and contributing to increased mortality in neurodegenerative diseases. OBJECTIVE An overview of currently applied therapeutic management options, primarily focused on specifically structured rehabilitation exercises, in conjunction with falls-risk assessment in the individuals affected by PS. METHODS A narrative literature review, augmented with the authors' own experience in physical rehabilitation management. RESULTS As individuals affected by PS are evidenced to be intrinsically exposed to higher falls-risk through acquired postural deformities, they often fall victims of traumatic accidents, occasionally also facing relocation into 24-hour nursing facilities due to the injuries sustained/resultant disability, consequently having overall quality of their life appreciably reduced. CONCLUSIONS sA comprehensive approach is postulated in designing optimal therapeutic management, comprised of the exercises controlling postural stability, whilst reducing lower back pain, and the ones also promoting specific skills essential for coping unassisted after an accidental fall effectively. Rehabilitation of individuals affected by PS should be a fully integrated service, eliminating all identified risk factors for falls. As clinical PS symptoms tend to recur after completion of a full course of therapeutic management, all PS patients should continue the pursuit of therapeutic exercises on an individual basis, to effectively retard their recurrence. In view of overall scarcity of clinical studies completed on the large population samples of PS patients, further in-depth research is still required to ensure higher credence to overall efficacy of the presently proposed therapeutic solutions.
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Affiliation(s)
- Marek Zak
- Institute of Health Sciences, Collegium Medicum, Jan Kochanowski University of Kielce, Kielce, Poland
| | - Tomasz Sikorski
- Doctoral School, Collegium Medicum, Jan Kochanowski University of Kielce, Kielce, Poland
| | - Magdalena Wasik
- Doctoral School, Collegium Medicum, Jan Kochanowski University of Kielce, Kielce, Poland
| | - Szymon Krupnik
- Symmetry, Medical Rehabilitation Centre, Sosnowiec, Poland
| | - Jaroslaw Andrychowski
- Institute of Health Sciences, Collegium Medicum, Jan Kochanowski University of Kielce, Kielce, Poland
| | - Waldemar Brola
- Institute of Health Sciences, Collegium Medicum, Jan Kochanowski University of Kielce, Kielce, Poland
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Use of Botulinum Neurotoxin in Parkinson's Disease: A Critical Appraisal. Toxins (Basel) 2021; 13:toxins13020087. [PMID: 33503872 PMCID: PMC7910947 DOI: 10.3390/toxins13020087] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 11/17/2022] Open
Abstract
For well over 30 years, the botulinum neurotoxin (BoNT) has been used for a large number of indications, some of which however have not been licensed. Admittedly, approval varies in many countries and this permits a large spectrum for evaluation. Thus, BoNT is used for patients with Parkinson’s disease (PD) and other Parkinson’s syndromes (PS) in varying degrees of frequency. We have to distinguish between (1) indications that are either approved or (2) those not approved, (3) indications that might be a result of PS and (4) finally those which appear independent of PS. The most important indication for BoNT in PS patients is probably sialorrhea, for which approval has been granted in the majority of countries. Cervical dystonia is a frequent symptom in PS, with anterocollis as a specific entity. A further indication is blepharospasm in the different forms, especially the inhibition of eyelid opening in atypical PS. The use of BoNT in cases of camptocormia, the Pisa syndrome and neck rigidity is still a matter of debate. In dystonia of the extremities BoNT can be recommended, especially in dystonia of the feet. One well-known indication, for which however sufficient data are still lacking, involves treating tremor with BoNT. As to autonomic symptoms: Focal hyperhidrosis and detrusor hyperactivity can be mentioned, in this last case BoNT has already been approved. A number of further but rare indications such as freezing-of-gait, dyskinesia, and dysphagia will be discussed and evaluated.
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Lena F, Etoom M, Al-Wardat M, Modugno N. Osteoporotic fracture and conservative management in Parkinson's disease and Pisa syndrome: Case report. J Bodyw Mov Ther 2020; 25:170-173. [PMID: 33714491 DOI: 10.1016/j.jbmt.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/18/2020] [Accepted: 11/07/2020] [Indexed: 11/27/2022]
Abstract
Osteoporotic fractures (OF) may occur without major trauma or injury. This case reports present a spine OF in Parkinson's disease (PD) and Pisa syndrome (PS). A 75-years-old woman diagnosed with PD for 19 years and PS has been developed. She recently has acute and severe low back pain. No recent injury or fall. After clinical examination and radiograph imaging, moderate wedge compression OF at L2 was revealed without a spinal cord or nerve compression. A program of conservative treatment was applied include antiosteoporotic supplementary, 6-days of bed rest, spine orthosis, and 10-weeks of exercises. The study adapted to use the following outcomes: visual analogues scale for low back pain, wall goniometer for lateral trunk flexion, and Oswesrty disability index for disability. After the intervention, the outcomes were improved as these values: visual analogues scales 7 points, lateral trunk flexion 20°, and Oswesrty disability index 60%. The case report suggests that the posture deformity as PS in PD may increase the risk of spine OF. The conservative treatment could be beneficial and safe for the OF in PD and PS. Further studies are required to confirm the role of PD postural deformities in OF and the effectiveness of therapeutic interventions.
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Affiliation(s)
- Francesco Lena
- INM, Neuromed, Pozzilli, Via Atinense, Pozilli, Isernia, Italy
| | - Mohammad Etoom
- Allied Medical Sciences Department, Division of Physical Therapy, Aqaba University of Technology, Aqaba, Jordan
| | - Mohammad Al-Wardat
- Allied Medical Sciences Department, Division of Physical Therapy, Aqaba University of Technology, Aqaba, Jordan.
| | - Nicola Modugno
- INM, Neuromed, Pozzilli, Via Atinense, Pozilli, Isernia, Italy
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