A case of levodopa-responsive camptocormia associated with advanced Parkinson's disease

Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions

Axial postural abnormalities (PA) are frequent, highly disabling, and drug-refractory motor complications affecting patients with Parkinson's disease (PD) or atypical parkinsonism. Over the past few years, advances have been reached across diagnosis, assessment, and pathophysiological mechanisms of PA. Nonetheless, their management remains a challenge, and these disturbances are generally overlooked by healthcare professionals, potentially resulting in their worsening and impact on patients' disabilities. From shared consensus-based assessment and diagnostic criteria, PA calls for interdisciplinary management based on the complexity and multifactorial pathogenesis. In this context, we conducted a systematic literature review to analyze the available pharmacological and non-pharmacological treatment options for PA in PD according to the new expert-based classification of axial PA in Parkinsonism. Different multidisciplinary approaches, including dopaminergic therapy adjustment, physiotherapy, botulinum toxin injection, and deep brain stimulation, can improve PA depending on its type and severity. An early, interdisciplinary approach is recommended in PD patients to manage PA.

Camptocormia, a Rare Complication of Hemorrhagic Stroke: A Case Report

Camptocormia (bent spine syndrome) is a rare complication after hemorrhagic stroke. It is a disabling, acquired postural abnormality that has a significant impact on a patient's physical function and quality of life and is more often seen in patients with Parkinson's disease. Treatment strategies pertaining to this condition can be broadly divided into invasive which involved deep brain stimulation and spinal fixation operation versus non-invasive approaches like physiotherapy, orthosis and drugs. However, most of the treatments described in the past are mainly for Parkinson's patients with camptocormia, and none are for camptocormia from hemorrhagic stroke. We report a rare case of camptocormia in a posthemorrhagic stroke patient whose rehabilitation progress was greatly impeded by this axial postural deformity and who responded well to Madopar treatment with an improvement in total camptocormia angle from 90 degrees to about 30 degrees, which translated to an improvement in physical function and reduction in care burden.

Subthalamic Stimulation for Camptocormia in Parkinson's Disease: Association of Volume of Tissue Activated and Structural Connectivity with Clinical Effectiveness

BACKGROUND

Deep brain stimulation of the subthalamic nucleus (STN-DBS) has been reported to be effective for camptocormia in Parkinson's disease (PD). However, the association between clinical effectiveness and the stimulated volumes or structural connectivity remains unexplored.

OBJECTIVE

To investigate the effectiveness of STN-DBS for treating camptocormia in PD and its association with volumes of tissue activated (VTA) and structural connectivity.

METHODS

We reviewed video recordings of patients who had undergone STN-DBS. The total and upper camptocormia (TCC and UCC) angles were measured to quantify changes in camptocormia. The Movement Disorders Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) was used to assess motor symptoms. Pre- and postoperative brain images were collected for modeling volume of VTA and structural connectivity using Lead-DBS software.

RESULTS

Participants included 36 patients with PD (8 with TCC-camptocormia and 2 with UCC-camptocormia) treated with bilateral STN-DBS. After surgery, patients showed a significant improvement in postural alignment at follow-up (mean follow-up duration: 6.0±2.2 months). In the entire sample, higher structural connectivity to the right supplementary motor area (SMA) and right lateral premotor cortex along the dorsal plane (PMd) was associated with larger postsurgical improvements in axial signs and TCC angles after stimulation was turned on. In patients diagnosed with camptocormia, larger improvement in camptocormia angles after STN-DBS was associated with a larger VTA overlap with STN (R = 0.75, p = 0.032).

CONCLUSION

This study suggests that both VTA overlap with STN and structural connectivity to cortical motor regions are associated with the effectiveness of STN-DBS for managing camptocormia in PD.

Recent advancements in lateral trunk flexion in Parkinson disease

Purpose of review

Understanding the pathophysiologic underpinnings of lateral trunk flexion (LTF) in Parkinson disease (PD) has been growing. Adjusting antiparkinsonian medications, botulinum toxin, or surgical intervention has been found efficacious in some patients. Nevertheless, these treatments remain limited, often resulting in inadequate outcomes. We review patients with LTF with PD, including recent advancements in treatment and neuroimaging examination.

Recent findings

The basal ganglia system is a major contributing factor to LTF, and the therapeutic intervention also targets the basal ganglia system, including dystonic contraction. The perceptions of the postural verticality or spatial cognition of the correct body orientation promote the severity of LTF or result in a chronic condition with irreversible structural deformities.

Conclusion

The combination of pharmacologic interventions with nonpharmacologic interventions, such as rehabilitation, might be needed to manage LTF, and the initiation of these treatments should be started as early as possible.

Wearable Sensor Based Stooped Posture Estimation in Simulated Parkinson's Disease Gaits

Stooping is a posture which is described as an involuntary forward bending of the thoracolumbar spine. Conventionally, the stooped posture (SP) in Parkinson’s disease patients is measured in static or limited movement conditions using a radiological or optoelectronic system. In the dynamic condition with long movement distance, there was no effective method in preference to the empirical assessment from doctors. In this research, we proposed a practical method for estimating the SP with a high accuracy where accelerometers can be mounted on the neck or upper back as a wearable sensor. The experiments with simulated subjects showed a high correlation of 0.96 and 0.99 between the estimated SP angle and the reference angles for neck and back sensor position, respectively. The maximum absolute error (0.9 and 1.5 degrees) indicated that the system can be used, not only in clinical assessment as a measurement, but also in daily life as a corrector.

Effectiveness of spinal cord stimulation for painful camptocormia with Pisa syndrome in Parkinson's disease: a case report

BACKGROUND

Spinal cord stimulation (SCS) has recently been reported to be effective for truncal postural abnormalities such as camptocormia and Pisa syndrome in Parkinson's disease. In this case report, we describe a case of a woman with Parkinson's disease in whom SCS was effective for painful camptocormia with Pisa syndrome.

CASE PRESENTATION

A 65-year-old woman was admitted to our hospital because of painful camptocormia. She had noticed resting tremor in the left upper limb and aprosody at 48 years of age. She was diagnosed as having Parkinson's disease (Hoehn & Yahr stage 1) at 53 years of age. Cabergoline was started during that same year, with subsequent addition of selegiline hydrochloride; the symptoms of parkinsonism disappeared. Wearing-off occurred when she was 57 years old, 3 years after starting carbidopa/levodopa, and truncal postural abnormalities-painful camptocormia with Pisa syndrome to the right-appeared at 58 years of age. These symptoms worsened despite adjustment of her oral medications, and deep brain stimulation (DBS) was performed when she was 60 years old. The truncal postural abnormalities improved after DBS, and she could travel abroad at 61 years of age. However, from 62 years of age, painful camptocormia with Pisa syndrome to the right reappeared. The pain was unsuccessfully treated with oral analgesics, radiofrequency coagulation of the dorsal and medial branches of the lumbar spinal nerve, and lumbar epidural block. Finally, SCS was performed for the pain relief. The pain disappeared immediately after SCS and her posture then gradually improved. Unified Parkinson's Disease Rating Scale score improved from 48 to 34 points and Timed Up and Go Test improved from 15 s to 7 s after SCS.

CONCLUSIONS

This case suggests that SCS may be effective for improving painful truncal postural abnormalities and motor complications of Parkinson's disease. Pain relief or a direct effect on the central nervous system by SCS was considered to explain the alleviation of these symptoms.

Can postural abnormality really respond to levodopa in Parkinson's disease?

OBJECTIVE

Abnormal postures affect motor function in Parkinson's disease (PD), potentially compromising the quality of life. The clinical efficacy of dopaminergic medications remains uncertain. Knowing what type of abnormal posture clearly responds to dopaminergic medication would facilitate the clinical management of PD. We investigated whether abnormal posture responded to dopamine challenge testing.

METHODS

We studied 24 consecutive patients with PD who had anterior trunk flexion (ATF) (n=13), antecollis (n=4), or lateral trunk flexion (LTF) (n=7). Levodopa was infused intravenously over the course of 30min. Before and after the levodopa infusion, the angle of the posture was measured with the use of "Image J" software.

RESULTS

After the infusion of levodopa, the angle of the overall abnormal posture significantly decreased (p<0.001). The angle of the abnormal posture significantly decreased in both natural position (p<0.001, p=0.002) and in a position with the back averted (p=0.003, p=0.029) in patients with ATF or antecollis, but did not change significantly in patients with LTF (p=0.099). The change in the angle differed significantly between patients with ATF and those with antecollis (p=0.017) and between patients with antecollis and those with LTF (p=0.008), but did not differ significantly between patients with ATF and those with LTF (p=0.052). The change in the angle in patients with abnormal posture related to the 'off' state was significantly greater than that in patients without abnormal posture related to the 'off' state (p<0.001).

CONCLUSION

Patients with LTF and some patients with ATF poorly respond to levodopa. Two phenotypes of levodopa-responsiveness exist in patients with abnormal posture, and this observation is associated with an 'off' state, especially in patients with ATF.

Subthalamic nucleus stimulation improves Parkinson's disease-associated camptocormia in parallel to its preoperative levodopa responsiveness

OBJECTIVE

The aim of this work was to identify factors predictive of postoperative improvement of camptocormia in patients with Parkinson's disease (PD) treated by subthalamic nucleus (STN) stimulation.

BACKGROUND

Camptocormia, one of the most disabling features of PD, often responds poorly to medical therapies. The reported effects of deep brain stimulation on PD-associated camptocormia vary, and preoperative characteristics affecting the surgical outcome remain unclear.

METHODS

We evaluated 17 patients with camptocormia whose preoperative off-medication thoracolumbar angle exceeded 45°. We used photographs to measure their thoracolumbar angle preoperatively, 3 months after surgery, and at the last follow-up (mean 36.5 months postoperatively) in status on-medication and off-medication. The patient age, duration of PD and camptocormia, daily medications, Unified Parkinson's Disease Rating Scale (UPDRS) subscores and the Schwab-England activity of daily living scale (S-E) were also recorded. Univariate analysis was performed to identify factors predictive of the postoperative improvement of camptocormia.

RESULTS

STN stimulation significantly improved the UPDRS subscores and S-E, and resulted in a reduction of daily medications 3 months post-treatment. The preoperative thoracolumbar angle (mean±SD) in status off-medication (84.0±29.5°) was significantly ameliorated 3 months postoperatively (49.8±29.3°) and at the last follow-up (54.8±28.3°). There was no correlation between the postoperative camptocormia improvement rate and preoperative parameters other than the duration and severity of camptocormia and the levodopa responsiveness of the thoracolumbar angle. Symptom duration negatively affected levodopa responsiveness.

CONCLUSIONS

STN stimulation improves PD-associated camptocormia in parallel with preoperative levodopa responsiveness. Long symptom duration interferes with levodopa responsiveness.

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.

Beneficial effect of levodopa therapy on stooped posture in Parkinson's disease

OBJECTIVE

This study was designated to quantitatively evaluate the effect of levodopa on spinal posture in patients with PD using a computer-assisted handheld SpinalMouse device.

METHODS

Prospective case-study involving 48 patients with definite PD. All patients were recruited between September 2011 and September 2013 and included 22 dopa-naïve, evaluated before and 3 months after initiation of treatment, and 26 patients with response fluctuations studied during the "off" and "on" states. The SpinalMouse instrument, a computer-assisted mechanical hand-held device, designed to noninvasively assess the curvature of the spine was guided along the midline of the vertebral column in upright, full flexion, and full extension positions to objectively assess spinal posture.

RESULTS

In the dopa-naïve patients, spinal incline in the upright position was 12.4±1.2° before and 7.6±1.3° after treatment; p=0.002. Corresponding area-under-the-curve (AUC) values were 131.7±8.0 cm(2) and 87.1±7.3 cm(2); p<0.0001. In the response fluctuations patients, spinal incline was 13.3±1.3° in the "off" and 9.3±1.2° in the "on" period; p=0.015. Corresponding AUC values were 144.6±9.2 cm(2) and 103.1±8.2 cm(2); p<0.0001.

CONCLUSIONS

This is the first study that objectively measured and quantified abnormalities of spinal posture in patients with PD. Findings suggest that levodopa does have a beneficial effect on anterior flexion of the thoracolumbar spine, and thus indicate that the disorder of stooped posture in PD is mediated, at least in part, by dopamine deficiency.

Effect of neurostimulation on camptocormia in Parkinson's disease depends on symptom duration

Although some reports on neurostimulation are positive, no effective treatment method for camptocormia in Parkinson's disease (PD) is known to date. We aim to identify prognostic factors for a beneficial DBS effect on camptocormia. In an observational cohort study, we investigated 25 idiopathic PD patients, who suffered additionally from camptocormia, and underwent bilateral neurostimulation of the subthalamic nucleus (STN) to improve classical PD symptoms. Using an established questionnaire, we examined deep brain stimulation (DBS) effects on camptocormia in addition to general neurostimulation effects. A beneficial neurostimulation effect on camptocormia was defined as an improvement in the bending angle of a least 50%. In 13 patients, the bending angle of camptocormia improved, in 12 patients it did not. A multifactorial analysis revealed a short duration between onset of camptocormia and start of neurostimulation to be the relevant factor for outcome. All patients with duration of camptocormia up to 1.5 years showed a beneficial effect; patients between 1.5 and ∼3 years showed mixed results, but none with a duration of more than 40 months improved except for 1 patient whose camptocormia was levodopa responsive. The bending angle was not a prognostic factor. Our data indicate that the main prognostic factor for a beneficial DBS effect on camptocormia is its short duration. As an explanation, we suggest that neurostimulation may improve camptocormia only as long as muscle pathology is limited. Our findings may help to elucidate the mode of action of neurostimulation. A prospective study is necessary. © 2015 International Parkinson and Movement Disorder Society

Characteristics of non-motor symptoms in patients with Parkinson's disease exhibiting camptocormia

OBJECTIVE

This study aims to investigate the differences in the prevalence and severity of NMS between patients with Parkinson's disease (PD) who manifest camptocormia and those who do not manifest camptocormia.

METHODS

A total of 50 PD patients with camptocormia and 50 gender and disease duration 1:1 matched patients with PD but without camptocormia were included in this case-control study. The severity of motor symptoms was assessed with the Unified PD Rating Scale (UPDRS) part III and Hoehn and Yahr (H&Y) staging. The prevalence and severity of NMS were assessed with non-motor symptom scale (NMSS).

RESULTS

Patients with PD exhibiting camptocormia showed significantly higher scores in UPDRS part III and H&Y staging than those who do not exhibit camptocormia (P < 0.05). The frequency of the cardiovascular domain with the item of "light-headedness/dizziness", the gastrointestinal domain with the item of "dribbling saliva", and the miscellaneous domain with the items of "taste or smell change", "weight change", and "excessive sweating" was significantly higher in PD patients with camptocormia compared with those without camptocormia (P < 0.05). The mean scores of sleep/fatigue and perceptual problems/hallucinations domains, the mood/apathy domain with the item of "feelings of nervousness" in PD patients with camptocormia were higher than in those without camptocormia (P < 0.05).

CONCLUSIONS

PD patients manifesting camptocormia are likely subjected to NMS than patients without camptocormia, especially autonomic and miscellaneous symptoms. These patients also suffered from more severe neuropsychiatric symptoms and sleep disorders.

Camptocormia in Chinese patients with Parkinson's disease

To investigate the frequency and clinical characteristics of camptocormia in Chinese PD patients, we included 705 patients with PD and studied the clinical features and prevalence of camptocormia. Forty-six (6.5%) patients presented with camptocormia at the time of evaluation. The mean disease duration of PD patients with camptocormia was significantly longer than that without camptocormia (P < 0.01). After adjusted for age and disease duration, compared with patients without camptocormia, PD patients with camptocormia presented with higher score of UPDRS part III (P < 0.01), higher H&Y stage (P < 0.01), higher score of Non-Motor Symptoms Scale (P < 0.01) and lower score of Mini-Mental Status Examination (P < 0.01). Binary logistic regression models indicated that camptocormia is associated with higher H&Y stage and UPDRS part III score. Camptocormia is not rare (6.5%) with the disease progression of PD in Chinese PD population and is associated with more advanced PD.

Camptocormia in idiopathic Parkinson's disease: a focal myopathy of the paravertebral muscles

The objective of our study was to describe the clinical features of camptocormia, an involuntary, marked flexion of the thoracolumbar spine in idiopathic Parkinson's disease (PD) and to understand its etiology. In a prospective, cross-sectional study, we examined 15 patients with PD and camptocormia using laboratory parameters, EMG, muscle magnetic resonance imaging, and biopsy of the paravertebral muscles. The clinical data were compared with a matched control group of PD patients without camptocormia, and the biopsies were compared with muscles from age-matched autopsies. Almost all the patients (median age, 68.0 years; 7 women) with camptocormia suffered from advanced PD. Camptocormia occurred at a median of 9.0 years after the PD diagnosis. Compared with our clinical control group, back pain was more frequent and less dopa-sensitive in the patients with camptocormia who suffered more often from additional diseases of the back. On EMG, we found mainly a myopathic pattern. The MRI of the paravertebral muscles showed localized changes ranging from edema with contrast enhancement, which are considered to be early signs, to atrophy and/or fatty degeneration, interpreted as late degenerative changes. Early signs were seen mainly during the first year and degenerative changes after 1.5 years. Biopsies revealed consistently myopathic changes and in some cases fatty degeneration. Clinical or electromyographic features favoring dystonia were absent. Camptocormia is a major disabling, non-fluctuating and levodopa-resistant complication of advanced PD. The cause of camptocormia in idiopathic PD is a focal myopathy. Our findings suggest that the myopathy has a progressive course, which finally leads to degeneration of the paravertebral muscles.

Effect of subthalamic deep brain stimulation on postural abnormality in Parkinson disease

OBJECT

Parkinson disease (PD) is often accompanied by various postural abnormalities such as camptocormia (bent spine) or Pisa syndrome (lateral flexion). The authors studied the effect of subthalamic nucleus deep brain stimulation (STN DBS) on postural abnormality in patients with PD.

METHODS

The authors retrospectively reviewed the clinical course of 18 patients who suffered from significant postural abnormality and underwent bilateral STN DBS. Patients whose preoperative posture score (Unified Parkinson's Disease Rating Scale III, item 28) was 2 or more in the "medication-on" state were enrolled in this study. Eight patients were considered to have camptocormia, and 10 patients were considered to have so-called Pisa syndrome. Nine patients showed apparent thoracolumbar spinal deformity on radiography. Most patients had significant motor fluctuations from levodopa.

RESULTS

In 13 patients with moderate postural abnormality (score of 2 on item 28), 9 patients improved soon after surgery, but 1 patient relapsed. Two patients improved gradually over a long period after surgery, whereas 2 patients did not improve at all. In 5 patients with severe postural abnormality (score of 3 or 4 on item 28), 2 patients improved slightly in the long-term follow-up period after surgery, but 3 patients did not improve at all.

CONCLUSIONS

Postural abnormality in patients with PD could be ameliorated by STN DBS, and therefore surgery should be considered before irreversible spinal deformity develops.

Spinal deformity and Parkinson disease: a treatment algorithm

OBJECT

The authors review the literature on the treatment of spinal deformity in patients with Parkinson disease (PD) and formulate a treatment algorithm.

METHODS

The authors provide representative cases of patients with PD and spinal deformity who underwent deep brain stimulation (DBS) or spinal surgery.

RESULTS

In patients with PD and spinal deformity who undergo spinal surgery there is a high rate of acute and delayed complications. Patients who undergo DBS, while having significantly fewer complications, often do not regain sagittal balance.

CONCLUSIONS

Cases involving PD and camptocormia have a high rate of complications when spinal surgery is performed. The authors prefer to offer spinal surgery only to patients with coexisting spinal stenosis causing radiculopathy or myelopathy. Patients with PD and camptocormia without spinal stenosis may be considered for DBS, but the results are mixed.

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.