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

Significant improvement after sensory tricks and trunk strength training for Parkinson's disease with antecollis and camptocormia: A case report

BACKGROUND

Patients with Parkinson's disease (PD) exhibit symptoms such as antecollis (AC) and camptocormia (CC). The pathology of these two conditions is unclear. Additionally, standard treatment methods have not been established. The article reports the case of a 65-year-old female patient with AC and CC who was treated with central and peripheral interventions to alleviate symptoms.

CASE SUMMARY

We present the case of a 65-year-old female PD patient with AC and CC. The course of the disease was 5 years. She was treated with rehabilitation strategies such as sensory tricks and trunk strength training. During the inpatient period, we compared and analyzed the patient's gait, rehabilitation assessment scale score, and angles of her abnormal trunk posture in the first week, the third week, and the fifth week. The patient's stride length increased, indicating that the patient's walking ability was improved. The Unified Parkinson's Disease Scale Part Three score and CC severity score decreased. Furthermore, the score of the other scale increased. In addition, the patient showed significant improvements in AC, upper CC, and lower CC angles.

CONCLUSION

This case study suggested that sensory tricks and trunk strength training are beneficial and safe for patients with AC and CC.

Impact of deep brain stimulation therapy on the vertebral sagittal balance in Parkinson's disease patients

Parkinson's disease (PD) is characterized by cardinal motor signs: 4-6 Hz resting tremor, rigidity, and bradykinesia. In addition, 3-18% of PD patients have camptocormia, an abnormal forward flexion of the thoracolumbar spine, which may have a negative impact on patients' quality of life. Different possible treatments have been suggested for such a condition, but no one is resolutive. This study aims to define the possible impact of DBS, with selective targeting on the dorsal-lateral region of the STN, on the sagittal balance of patients affected by PD. Among all patients that have undergone DBS procedures in our institution, we selected eight subjects, four females and four males, with selective targeting on the dorsal-lateral region of the subthalamic nucleus (STN) because of camptocormia and other severe postural changes. Radiological assessments of spinal balance parameters before surgery and at 6 and 12 months postoperatively were carried out. Comparison of preoperative and postoperative spine X-ray data showed a statistically significant improvement in dorsal kyphosis angle (D-Cobb) 12 months after the operation. Deep brain stimulation with selective targeting of the dorsal lateral part of the STN may induce changes of the posture in patients with Parkinson's disease 12 months after the operation, which appears to improve in this small sample size, but larger observational and controlled trials would be required to confirm this observation.

Do cervical stabilization exercises change the effects of conventional exercises in patients with Parkinson's disease?

OBJECTIVES

The aim of this study was to examine whether cervical stabilization exercises (CSEs) change the effects of conventional exercises (CEs) in patients with PD.

METHODS

Twenty-five patients with PD were randomized into two groups. While the experimental group (EG) received CSEs in addition to CEs, the control group (CG) received only CEs. Both programs lasted 8 weeks. Eighteen participants were able to complete the study. The outcomes were the changes in posture, cervical joint position sense (JPS), balance assessment, 10-m walking tests (10MWT), and the Timed Up & Go (TUG) test.

RESULTS

At the end of the study, significant improvement was observed in both groups in terms of trunk rotation angle and pelvic asymmetry, the time parameter of TUG, and the 10MWT (p < 0.05). In the EG, greater improvement was detected in the Berg Balance Scale, static posturography, postural alignment, JPS, and the cadence parameter of TUG (p < 0.05).

DISCUSSION

CEs and CSEs could improve walking speed and posture in patients with PD, but if CSEs are added to CEs, greater improvements could be achieved in JPS and postural control.(Clinical Trials ID: NCT03854747).

Myofibrillar myopathy: a rare but important differential diagnosis of camptocormia in a patient with Parkinson's Disease

Here we report on a patient with Parkinson's Disease and camptocormia due to Myofibrillar Myopathy Type 3. By leading the reader through the clinical reasoning process and highlighting the respective red flags we aim to increase the readers' awareness for the differential diagnosis of camptocormia.

Axial posture disorders in Parkinson's disease: Clinical correlates and future treatment directions1

BACKGROUND

Postural disorders are frequently observed in Parkinson's disease (PD). The underlying mechanisms that cause postural disorders are not fully understood and the majority of these disorders have no response to antiparkinsonian treatments. These disabling conditions require further investigation to better understand the underlying mechanisms in order to develop effective treatments.

OBJECTIVE

The aim of this study was to investigate the frequency of axial postural disorders in PD and to determine the associated clinical risk factors.

METHODS

In this single-center clinical trial, the data of PD patients were reviewed retrospectively. The frequencies of postural disorders were determined, and the demographic clinical characteristics of the patients were compared.

RESULTS

The records of 127 patients with idiopathic PD were analyzed. Axial posture disorders were found in 42.6% of patients. Patients with axial posture disorders were older when the disease onset was detected, amongst these patients the condition was also longer lasting. The mean levodopa dose was higher in the patients with posture disorders. The initial symptom was bradykinesia and the Hoehn and Yahr's score was ⩾ 3 in the majority of the patients with posture disorder. Additionally, constipation, hallucinations, postural instability, and falls were significantly more common in patients with posture disorders.

CONCLUSION

Posture disorders were observed in nearly half of PD patients and were more frequently observed in patients with an advanced condition. In addition, our investigation has found that it is crucial to follow up with patients who present with bradykinesia for the development of postural disorder.

Deep brain stimulation for Parkinson's disease-related postural abnormalities: a systematic review and meta-analysis

Deep brain stimulation (DBS) has become a well-established treatment modality for Parkinson's disease (PD), especially regarding motor fluctuations, dyskinesias, and tremor. Although postural abnormalities (i.e., Camptocormia [CC] and Pisa syndrome [Pisa]) are known to be a major symptom of PD as well, the influence of DBS on postural abnormalities is unclear. The objective of this study is to analyze the existing literature regarding DBS for PD-associated postural abnormalities in a systematic review and meta-analysis. In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review and meta-analysis of 18 studies that reported the effect of DBS regarding postural abnormalities. After screening of 53 studies, a total of 98 patients (44 female, 53 males, 1 not reported; mean age: 62.3, range 30-83 years) with postural abnormalities (CC n = 98; Pisa n = 11) were analyzed from 18 included studies. Of those patients, 94.9% underwent STN-DBS and 5.1% had GPi as DBS target area. A positive outcome was reported for 67.8% with CC and 72.2% with Pisa. In the meta-analysis, younger age and lower pre-operative UPDRS-III (ON/OFF) were found as positive predictive factors for a positive effect of DBS. DBS might be a potentially effective treatment option for PD-associated postural abnormalities. However, the level of evidence is rather low, and definition of postoperative outcome is heterogenous between studies. Therefore larger, prospective trials are necessary to give a clear recommendation.

Surgical Correction of Kyphosis in Patients With Camptocormia Associated With Parkinson’s Disease: A Case Report and Review of the Literature

Background

Camptocormia is a postural deformity that is characterized by a markedly flexed lumbar spine, with symptoms that worsen with walking and standing. Here, we report a case of camptocormia associated with Parkinson’s disease.

Case description

A 70-year-old man with a 7-year history of Parkinson’s disease presented with a fall injury that caused lower back pain for 3 months and was aggravated for 2 months. He had been diagnosed with a compression fracture after the fall and had undergone percutaneous kyphoplasty at a local hospital. MRI showed non-union of the L1 vertebra and compression fracture of L2. The patient underwent posterior osteotomy, canal decompression, and internal fixation of the T10-L3 intervertebral plate with bone graft fusion. Postoperative examination showed that the lumbar lordosis was corrected and sensation was restored in both lower extremities. However, after 1 month, the fixation was loosened and a correction surgery was performed at our hospital. At the most recent follow-up at 1.5 years, the patient was found to be in good general health and did not complain of lower back discomfort. He was also actively exercising according to the rehabilitation regimen and had resumed social life.

Conclusion

This is a rare case of camptocormia in a Parkinson’s patient that highlights the need for careful evaluation of whether internal spinal fixation surgery is beneficial in such patients.

Relationship between Lower Limbs Performance and Spinal Alignment in Parkinson’s Disease Patients: An Observational Study with Cross Sectional Design

Parkinson’s disease (PD) is a progressive neurodegenerative disease determining spinal deformities and muscle rigidity, weakness and dystonia that can be related to a change in muscular output during sit-to-stand tasks (STS). Purpose: The aim of this study was to determine the impacts of spinal alignment on lower limbs performance during STS tasks in Parkinson’s disease (PD) patients and healthy controls. Methods: In total, 43 consecutive PD patients (“PD” Group, 25 males and 18 females; age 73.7 ± 7.1) and 42 people not affected by any type of neurological disease (“CON” Group, 22 males, 20 females; age 69.8 ± 6.0) participated in the observational study. The clinical assessment included: IPAQ (International Physical Activity Questionnaire), Hoehn Yahr score, plumb-line distance from the spinous process of C7, kyphosis apex and the spinous process of L3 and S1. We used the Muscle Quality Index test (MQI) to assess muscle power output during STS in both groups. Results: The MQI test measurements of absolute and relative lower limb power was significantly lower in the PD group, in addition to a negative correlation with age and a positive correlation with PL-L3 in that group of patients. Conclusions: A final consideration regarding our results leads to the possibility that the preservation of lumbar lordosis may be one of the factors for maintaining efficient biomechanics of the lower limb muscles, with the preservation of the physiological contractile characteristics of these muscles being the objective for a multidisciplinary rehabilitation based on postural exercises of the spine and a program of training exercises for the lower limb muscles.

Comparison of erector spinae fatigability between female patients with Parkinson's disease and healthy individuals: a cross sectional pilot study

BACKGROUND

Postural abnormality is one of the main symptoms of Parkinson's disease (PD). The erector spinae muscles play an important role in maintaining an upright posture, but the fatigability of the erector spinae in patients with PD is unknown. The purpose of this study was to compare the trunk extension maximum voluntary contraction (MVC) and the fatigability of the erector spinae between female patients with PD and healthy volunteers.

METHODS

Th participants of this cross-sectional pilot study comprised 19 patients with PD and nine healthy volunteers matched for sex, age, and physical characteristics as a control group. The MVC of all participants was measured, and after sufficient rest, the Sørensen back endurance test was conducted to the point of exhaustion. The muscle activity of the erector spinae during the Sørensen back endurance test was measured using surface electromyography. The median frequency (MF) slope, which is an index of fatigability, was calculated from the recorded surface muscle activity by means of power spectrum analysis using a Fast Fourier transformation.

RESULTS

Nine of the 19 patients with PD were unable to perform the Sørensen back endurance test, and a lower proportion of the PD group were able to perform it compared with the control group. The MVC of those patients with PD who were able to perform the Sørensen back endurance test was lower than that of the control group, and the time for which the pose could be maintained was shorter. There was no significant difference between the MF slope on the left and right side in the PD group, and it was higher on both sides than in the control group.

CONCLUSION

This is the first study to demonstrate a reduction of maximum muscle strength and great fatigability of the erector spinae in patients with PD. This discovery strongly underlines the need for paraspinal muscle training from an early stage with the aim of preventing the progression of postural abnormality in patients with PD.

Deep brain stimulation in the subthalamic nuclei alters postural alignment and adaptation in Parkinson's disease

Parkinson’s disease (PD) can produce postural abnormalities of the standing body position such as kyphosis. We investigated the effects of PD, deep brain stimulation (DBS) in the subthalamic nucleus (STN), vision and adaptation on body position in a well-defined group of patients with PD in quiet standing and during balance perturbations. Ten patients with PD and 25 young and 17 old control participants were recruited. Body position was measured with 3D motion tracking of the ankle, knee, hip, shoulder and head. By taking the ankle as reference, we mapped the position of the joints during quiet standing and balance perturbations through repeated calf muscle vibration. We did this to explore the effect of PD, DBS in the STN, and vision on the motor learning process of adaptation in response to the repeated stimulus. We found that patients with PD adopt a different body position with DBS ON vs. DBS OFF, to young and old controls, and with eyes open vs. eyes closed. There was an altered body position in PD with greater flexion of the head, shoulder and knee (p≤0.042) and a posterior position of the hip with DBS OFF (p≤0.014). With DBS ON, body position was brought more in line with the position taken by control participants but there was still evidence of greater flexion at the head, shoulder and knee. The amplitude of movement during the vibration period decreased in controls at all measured sites with eyes open and closed (except at the head in old controls with eyes open) showing adaptation which contrasted the weaker adaptive responses in patients with PD. Our findings suggest that alterations of posture and greater forward leaning with repeated calf vibration, are independent from reduced movement amplitude changes. DBS in the STN can significantly improve body position in PD although the effects are not completely reversed. Patients with PD maintain adaptive capabilities by leaning further forward and reducing movement amplitude despite their kyphotic posture.

From Collar to Coccyx: Truncal Movement Disorders: A Clinical Review

Background

Movement disorders affecting the trunk remain a diagnostic challenge even for experienced clinicians. However, despite being common and debilitating, truncal movement disorders are rarely discussed and poorly reviewed in the medical literature.

Objectives

To review common movement disorders affecting the trunk and provide an approach for clinicians based on the truncal region involved (shoulder, chest, diaphragm, abdomen, pelvis, and axial disorders). For each disorder, clinical presentation, etiologic differential diagnosis, and "clinical clues" are discussed.

Conclusion

This review provides a clinically focused, practical approach to truncal movement disorders, which will be helpful for physicians in everyday practice.

Palmitoylethanolamide/Luteolin as Adjuvant Therapy to Improve an Unusual Case of Camptocormia in a Patient with Parkinson's Disease: A Case Report

BACKGROUND

Camptocormia is a complication in which the spine bends forward while walking or standing. This axial postural deformity is common in Parkinson's disease (PD), with prevalence ranging from 3 to 18 percent; it is generally associated with a more severe disease and longer duration of symptoms. Camptocormia in PD typically responds poorly to levodopa. Other treatment options are limited and are often not effective.

CASE PRESENTATION

We describe an unusual case of PD presenting with camptocormia that only emerged during the "off" state of PD. The patient was treated with classical dopaminergic anti-Parkinson's therapy plus a new formulation of palmitoylethanolamide co-ultramicronized with luteolin (Lut) termed um-PEALut. We observed that the addition of um-PEALut to acute treatment with carbidopa/levodopa resulted in improved dyskinesia and reduced camptocormia. The patient continued treatment for four months, resulting in a complete resolution of leg and trunk dyskinesia and a marked reduction in the onset of camptocormia during the "off" states.

CONCLUSION

um-PEALut shows potential as an efficacious adjuvant therapy for patients with PD receiving carbidopa/levodopa to treat both dyskinesia and camptocormia in acute and chronic fashion.

Camptocormia in patients with multiple system atrophy at different disease durations: frequency and related factors

Background

Camptocormia is common in patients with multiple system atrophy (MSA). The current study was aimed at assessing the frequency of camptocormia and its related factors in MSA patients with different disease durations. Also, the impact of camptocormia on disability was evaluated.

Methods

A total of 716 patients were enrolled in the study. They were classified into three groups based on disease duration (≤ 3, 3–5, ≥ 5 years). Specific scales were used to evaluate the motor and non-motor symptoms. Disease severity was assessed using the Unified Multiple System Atrophy Rating Scale (UMSARS). The binary logistic regression model was used to explore the factors related to camptocormia. To analyze the impact of camptocormia on disability in patients with disease duration less than 5 years, propensity score matching (PSM) and stratified Cox regression analysis were used.

Results

In the current study, we found that the frequency of camptocormia was 8.9, 19.7 and 19.2% when the disease duration was ≤3, 3–5, ≥ 5 years, respectively. In the disease duration ≤3 years group, we found that MSA-parkinsonian subtype (MSA-P) (OR = 2.043, P = 0.043), higher total UMSARS score (OR = 1.063, P < 0.001), older age of onset (OR = 1.047, P = 0.042), and lower score on the frontal assessment battery (FAB) (OR = 0.899, P = 0.046) were associated with camptocormia. Only greater disease severity was associated with camptocormia in the group of patients with disease duration 3–5 years (OR = 1.494, P = 0.025) and in the group of patients with disease duration ≥5 years (OR = 1.076, P = 0.005). There was no significant impact of camptocormia on disability in patients with a disease duration of < 5 years (HR = 0.687, P = 0.463).

Conclusion

The frequency of camptocormia increased with prolonged disease duration. Disease severity was related to camptocormia at different stages of the disease. The MSA-P subtype, older age of onset, and lower FAB score were associated with camptocormia in the early stage of the disease.

Measurement and Correction of Stooped Posture during Gait Using Wearable Sensors in Patients with Parkinsonism: A Preliminary Study

Stooped posture, which is usually aggravated during walking, is one of the typical postural deformities in patients with parkinsonism. However, the degree of stooped posture is difficult to quantitatively measure during walking. Furthermore, continuous feedback on posture is also difficult to provide. The purpose of this study is to measure the degree of stooped posture during gait and to investigate whether vibration feedback from sensor modules can improve a patient's posture. Parkinsonian patients with stooped posture were recruited for this study. Two wearable sensors with three-axis accelerometers were attached, one at the upper neck and the other just below the C7 spinous process of the patients. After being calibrated in the most upright posture, the sensors continuously recorded the sagittal angles at 20 Hz and averaged the data at every second during a 6 min walk test. In the control session, the patients walked with the sensors as usual. In the vibration session, sensory feedback was provided through vibrations from the neck sensor module when the sagittal angle exceeded a programmable threshold value. Data were collected and analyzed successfully in a total of 10 patients. The neck flexion and back flexion were slightly aggravated during gait, although the average change was <10° in most patients in both measurement sessions. Therefore, it was difficult to evaluate the effect of sensory feedback through vibration. However, some patients showed immediate response to the feedback and corrected their posture during gait. In conclusion, this preliminary study suggests that stooped posture could be quantitatively measured during gait by using wearable sensors in patients with parkinsonism. Sensory feedback through vibration from sensor modules may help in correcting posture during gait in selected patients.

Use of Botulinum Neurotoxin in Parkinson's Disease: A Critical Appraisal

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.

From the Gut to the Brain and Back: Therapeutic Approaches for the Treatment of Network Dysfunction in Parkinson's Disease

Parkinson's disease (PD) is a complex, multisystem, progressive, degenerative disorder characterized by severe, debilitating motor dysfunction, cognitive impairments, and mood disorders. Although preclinical research has traditionally focused on the motor deficits resulting from the loss of nigrostriatal dopaminergic neurons, up to two thirds of PD patients present separate and distinct behavioral changes. Loss of basal forebrain cholinergic neurons occurs as early as the loss of dopaminergic cells and contributes to the cognitive decline in PD. In addition, attentional deficits can limit posture control and movement efficacy caused by dopaminergic cell loss. Complicating the picture further is intracellular α-synuclein accumulation beginning in the enteric nervous system and diffusing to the substantia nigra through the dorsal motor neurons of the vagus nerve. It seems that α-synuclein's role is that of mediating dopamine synthesis, storage, and release, and its function has not been completely understood. Treating a complex, multistage network disorder, such as PD, likely requires a multipronged approach. Here, we describe a few approaches that could be used alone or perhaps in combination to achieve a greater mosaic of behavioral benefit. These include (1) using encapsulated, genetically modified cells as delivery vehicles for administering neuroprotective trophic factors, such as GDNF, in a direct and sustained means to the brain; (2) immunotherapeutic interventions, such as vaccination or the use of monoclonal antibodies against aggregated, pathological α-synuclein; (3) the continuous infusion of levodopa-carbidopa through an intestinal gel pad to attenuate the loss of dopaminergic function and manage the motor and non-motor complications in PD patients; and (4) specific rehabilitation treatment programs for drug-refractory motor complications.

Clinical Perspectives of Parkinson's Disease for Ophthalmologists, Otorhinolaryngologists, Cardiologists, Dentists, Gastroenterologists, Urologists, Physiatrists, and Psychiatrists

Parkinson's disease (PD) is a multisystemic disorder characterized by various non-motor symptoms (NMS) in addition to motor dysfunction. NMS include sleep, ocular, olfactory, throat, cardiovascular, gastrointestinal, genitourinary, or musculoskeletal disorders. A range of NMS, particularly hyposmia, sleep disturbances, constipation, and depression, can even appear prior to the motor symptoms of PD. Because NMS can affect multiple organs and result in major disabilities, the recognition and multidisciplinary and collaborative management of NMS by physicians is essential for patients with PD. Therefore, the aim of this review article is to provide an overview of the organs that are affected by NMS in PD together with a brief review of pathophysiology and treatment options.

Muscle echo intensity of abdominal wall in Parkinson's disease and healthy controls: a cross sectional study

PURPOSE

The aim of this study was to describe the differences between abdominal wall muscles echo intensity (EI) in PD patients and healthy controls.

METHODS

Forty-three consecutive PD patients (25 males and 18 females, age 73.7 ± 7.1, and 42 controls without neurological diseases (22 males, 20 females, age 69.8 ± 6.0) participated in this cross-sectional study. The clinical assessment included the following: IPAQ (International Physical Activity Questionnaire), Hoehn Yahr score, plumb line distance from the spinous process of C7, kyphosis apex, and spinous process of L3 and S1. A real-time ultrasound B-scanner (system MyLab40 by Esaote, Genoa, Italy) was used to obtain muscle images of the right and left biceps brachii (BB), external (EO), and internal oblique (IO) and rectus abdomen (RA). Heckmatt scale and measure of EI through ImageJ software were used to assess muscle quality.

RESULTS

When considering the Heckmatt score, the RA and BB did not significantly differ between PD and control patients, while there was a significant difference for right (p < 0.01) and left (p = 0.02) IO muscles. There was no difference among EI values of the RA, IO, and BB between PD and control patients.

CONCLUSIONS

Echo intensity of abdominal wall muscles (rectus abdominis, internal oblique) and biceps brachii did not differ between Parkinsonian patients and healthy subjects. We did not found ultrasound useful in disease evolution assessment or in early diagnosis of postural disorders.

Does the Degree of Trunk Bending Predict Patient Disability, Motor Impairment, Falls, and Back Pain in Parkinson's Disease?

Background: Postural abnormalities in Parkinson's disease (PD) form a spectrum of functional trunk misalignment, ranging from a "typical" parkinsonian stooped posture to progressively greater degrees of spine deviation. Objective: To analyze the association between degree of postural abnormalities and disability and to determine cut-off values of trunk bending associated with limitations in activities of daily living (ADLs), motor impairment, falls, and back pain. Methods: The study population was 283 PD patients with ≥5° of forward trunk bending (FTB), lateral trunk bending (LTB) or forward neck bending (FNB). The degrees were calculated using a wall goniometer (WG) and software-based measurements (SBM). Logistic regression models were used to identify the degree of bending associated with moderate/severe limitation in ADLs (Movement Disorders Society Unified PD Rating Scale [MDS-UPDRS] part II ≥17), moderate/severe motor impairment (MDS-UPDRS part III ≥33), history of falls (≥1), and moderate/severe back pain intensity (numeric rating scale ≥4). The optimal cut-off was identified using receiver operating characteristic (ROC) curves. Results: We found significant associations between modified Hoehn & Yahr stage, disease duration, sex, and limitation in ADLs, motor impairment, back pain intensity, and history of falls. Degree of trunk bending was associated only with motor impairment in LTB (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.03-1.22). ROC curves showed that patients with LTB of 10.5° (SBM, AUC 0.626) may have moderate/severe motor impairment. Conclusions: The severity of trunk misalignment does not fully explain limitation in ADLs, motor impairment, falls, and back pain. Multiple factors possibly related to an aggressive PD phenotype may account for disability in PD patients with FTB, LTB, and FNB.

The Effect of Medication and Deep Brain Stimulation on Posture in Parkinson's Disease

Introduction: Postural abnormalities are common in Parkinson's disease (PD) and increasing with disease progression. While many studies focus on balance and gait, postural alignment is only infrequently studied.

Purpose: The aim of the present study was to examine the immediate and long-term effects of medication and deep brain stimulation (DBS) in the subthalamic nucleus on postural alignment in PD.

Materials and Methods: PD patients (n = 192) in an advanced stage of disease were videotaped during a standardized l-dopa trial before and after DBS. The patients were tested with and without medication pre-surgical and retested post-surgical (6–24 months) in all treatment combinations of medication and DBS regarding the on and off conditions. The forward bending as total camptocormia (TCC) and upper camptocormia (UCC) angles and lateral bending as Pisa angle were assessed with the free downloadable NeuroPostureApp (http://www.neuroimaging.uni-kiel.de/NeuroPostureApp/). Three subgroups were defined according to normative values of healthy controls and according to clinical criteria: patients with normal posture, with stooped posture, and with postural disorders.

Results: A stooped posture was found in 82% of the patients with regard to the TCC angle and in 54% for the UCC angle. Sixty-two percent had an abnormal Pisa angle. Camptocormia was diagnosed in ~7% and a Pisa syndrome in 1% of the patients. Medication and DBS both significantly improved postural alignment in the entire cohort. Female and male patients benefit similarly by medication and stimulation. Subgroup analyses revealed that the effects were also significant for patients with stooped posture, and the effects were strongest for patients with camptocormia: they led to angles below the diagnostical criterion for camptocormia for 13 of 14 patients with TCC and 11 of 26 patients with UCC. DBS had an additional effect to medication over time for the Pisa angle.

Conclusion: Medication and DBS both improved postural alignment in PD patients, but effects were small for the entire cohort. Patients with camptocormia according to the TCC angle benefit strongest. The large differences of the treatment effects may indicate distinct pathological mechanisms for stooped posture and postural disorders. The TCC angle was shown to be sensitive to change. The UCC angle was less sensitive but may be a useful assessment tool for a subgroup.

Effects of Deep Brain Stimulation on Postural Trunk Deformities: A Systematic Review

Background

Deep brain stimulation (DBS) effects on postural deformities are still poorly explored.

Methods

Systematic review in accord with the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines (PRISMA).

Results

All 38 studies that met predefined eligibility criteria had high risk of bias attributed to retrospective analysis of heterogeneous populations with variable and incompletely reported demographic and clinical characteristics, definitions, outcomes, DBS indications, targets, and settings. Five patient groups were identified in the 35 studies with individual data available: (1) parkinsonian camptocormia (n = 96): 89 patients underwent subthalamic (STN) and 7 globus pallidus pars interna (GPi) DBS. Camptocormia was the indication in 3 patients. After DBS, camptocormia improved in 57 of 96 patients (4.3-100% improvement) and remained stable or worsened in 39 of 96 patients (2-100% worsening). (2) dystonic camptocormia (n = 16): All underwent GPi-DBS. They were younger and with shorter disease duration, but longer deformity duration, compared with parkinsonian camptocormia. After GPi-DBS, camptocormia improved in all patients (50-100% improvement). (3) Parkinsonian Pisa syndrome (n = 14): 11 patients underwent STN-DBS for motor fluctuations whereas Pisa syndrome was the indication for pedunculopontine and GPi-DBS in 2 patients. After DBS, Pisa improved in 10 of 14 patients (33.3-66.7% improvement). (4) Dystonic opisthotonus: 2 young patients remarkably responded to GPi-DBS. (5) Parkinsonian anterocollis: There were variable responses in 3 patients after STN-DBS for motor fluctuations.

Conclusions

Low-quality level of evidence suggests that dystonic camptocormia and opisthotonus improve after GPi-DBS. Parkinsonian camptocormia, Pisa syndrome, and anterocollis have variable responses, and their dystonic features should be further explored.

Postural Abnormalities in Parkinson's Disease: An Epidemiological and Clinical Multicenter Study

INTRODUCTION

The overall frequency of postural abnormalities (PA) in Parkinson's disease (PD) is unknown. We evaluated the overall prevalence of PA and assessed the association with demographic and clinical variables.

METHODS

For this multicenter, cross-sectional study, consecutive PD outpatients attending 7 tertiary Italian centers were enrolled. Patients were evaluated and compared for the presence of isolated PA such as camptocormia, Pisa syndrome, and anterocollis and for combined forms (ie, camptocormia + Pisa syndrome) together with demographic and clinical variables.

RESULTS

Of the total 811 PD patients enrolled, 174 (21.5%; 95% confidence interval [CI], 18.6%-24.3%) presented PA, 144 of which had isolated PA and 30 had combined PA. The prevalence of camptocormia was 11.2% (95% CI, 9%-13.3%), Pisa syndrome 8% (95% CI, 6.2%-9.9%), and anterocollis 6.5% (95% CI, 4.9%-8.3%). Patients with PA were more often male and older with longer disease duration, more advanced disease stage, more severe PD symptoms, a bradykinetic/rigid phenotype, and poorer quality of life. They were initially treated with levodopa, and more likely to be treated with a combination of levodopa and dopamine agonist, took a higher daily levodopa equivalent daily dose, and had more comorbidities. Falls and back pain were more frequent in PD patients with PA than in those without PA. Multiple logistic regression models confirmed an association between PA and male gender, older age, Hoehn and Yahr stage, and total Unified Parkinson's Disease Rating Scale score.

CONCLUSIONS

PA are frequent and disabling complications in PD, especially in the advanced disease stages.

Do Upper and Lower Camptocormias Affect Gait and Postural Control in Patients with Parkinson's Disease? An Observational Cross-Sectional Study

Gait impairments and camptocormia (CC) are common and debilitating in patients with Parkinson's disease (PD). Two types of CC affect patients with PD, but no studies investigated their relative contribution in worsening gait and postural control. Therefore, we investigated spatiotemporal gait parameters, gait variability, and asymmetry and postural control in PD patients (Hoehn & Yahr ≤4) with upper CC and lower CC and patients without CC. This observational cross-sectional study involving patients with PD and upper CC (n=16) and lower CC (n=14) and without CC (n=16). The primary outcome measure was gait speed assessed by the GAITRite System. The secondary outcome measures were other spatiotemporal parameters, gait variability, and asymmetry. Postural control and balance were assessed with posturography and the Mini-BESTest. Patients with lower CC showed a higher H&Y stage (p=0.003), a worse PDQ8 (p=0.042), and a lower Mini-BESTest score (p=0.006) than patients with PD without CC. Patients with lower CC showed a reduced gait speed (p=0.012), stride length, and velocity than patients with PD without CC. Upper CC patients showed a higher stride length than lower CC ones (p=0.007). In the eyes open and closed condition, patients with lower CC showed a higher (worse) velocity of CoP displacement in mediolateral direction and length of CoP than patients with PD without CC. No significant between-group differences were measured in gait variability and asymmetry. In conclusion, lower CC was associated with more severe gait and postural control impairment than patients with upper CC and without CC. Categorizing CC based on the bending fulcrum is compulsory to identify patients with the worst performance and to implement specific rehabilitation programs.

Use of botulinum toxin for movement disorders

The term movement disorders encompasses all disorders hypokinetic and hyperkinetic, which were previously known as extrapyramidal syndromes. With the definition of movement disorders and their diagnostic criteria and classifications, new studies for therapeutics could be performed. New drugs were launched, functional neurosurgery was developed, and the introduction of botulinum toxin (BoNT) for hyperkinesias was introduced. BoNT is an important therapy for dystonia, tics, myoclonus, and tremors. The aim of this review is to present the new and well-established uses of BoNT for movement disorders.

Hand, foot, and spine deformities in parkinsonian disorders

Hand and foot deformities, known as "striatal deformities", and other musculoskeletal abnormalities such as dropped head, bent spine, camptocormia, scoliosis and Pisa syndrome, are poorly understood and often misdiagnosed features of Parkinson's disease and other parkinsonian syndromes. These deformities share some similarities with known rheumatologic conditions and can be wrongly diagnosed as rheumatoid arthritis, osteoarthritis, psoriatic arthritis, Dupuytren's contracture, trigger finger, or other rheumatologic or orthopedic conditions. Neurologists, rheumatologists, and other physicians must be familiar with these deformities to prevent misdiagnosis and unnecessary diagnostic tests, and to recommend appropriate treatment options.

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.

Body height loss characterizes camptocormia in Parkinson's disease

Axial deformities such as camptocormia or Pisa syndrome in people with Parkinson's disease (PwP) are poorly understood. The scarcity of information may result from the shortage of reliable and responsive evaluation instruments. We evaluated the body height loss (BHL) as a new measure for PwP with axial deformities. 50 PwP with axial deformity defined by an UPDRS item 28 value of at least 2 were included in this mono-center study. We measured body height while lying supine and after 1 min of standing, providing a percentage value of BHL, and compared this measure to other clinical variables. BHL depended on the Hoehn and Yahr clinical stage and correlated with clinical scales for function and mobility, but not with timely measures of the axial disorder such as age at diagnosis or duration of disease. ANOVA showed that only lumbar flexion explained the variability of BHL (F = 21.0, p < 0.0001), but not kyphosis (F = 0.4, p = 0.74) or lateroflexion (F = 0.6, p = 0.6). Re-test reliability of BHL was good with к = 0.76 (p < 0.0001). BHL resulted from the lumbar spine and the hip joint and not from the thoracic spine or lateroflexion. This observation conforms to the concept of upper-type and lower-type camptocormia with only the latter leading to a BHL. The assessment of the BHL is shown to be a well defined, easy to perform, and reliable measure for the clinical evaluation of lower-type camptocormia.

Diagnostic criteria for camptocormia in Parkinson's disease: A consensus-based proposal

INTRODUCTION

Camptocormia is defined as an involuntary, marked flexion of the thoracolumbar spine appearing during standing or walking and resolving in the supine position or when leaning against a wall. However, there is no established agreement on the minimum degree of forward flexion needed to diagnose camptocormia. Likewise, the current definition does not categorize camptocormia on the basis of the bending fulcrum.

METHODS

We performed a survey among movement disorders experts to identify camptocormia using images of patients with variable degrees and types of forward trunk flexion by fulcrum (upper and lower fulcra). We tested the subsequently generated diagnostic criteria in a sample of 131 consecutive patients referred for evaluation of postural abnormalities.

RESULTS

Experts reached full consensus on lower camptocormia (L1-Sacrum, hip flexion) with a bending angle ≥30° and upper camptocormia (C7 to T12-L1) with a bending angle ≥45°. This definition detected camptocormia in 9/131 consecutive PD patients (2 upper/7 lower) but excluded camptocormia in 71 patients considered to have camptocormia by the referring neurologist.

CONCLUSIONS

Camptocormia can be defined as "an involuntary flexion of the spine appearing during standing or walking and resolving in the supine position of at least 30° at the lumbar fulcrum (L1-Sacrum, hip flexion, i.e. lower camptocormia) and/or at least 45° at the thoracic fulcrum (C7 to T12-L1, i.e. upper camptocormia)". Strict criteria for camptocormia are met by 7% of patients with abnormal posture. The ascertainment of upper and lower camptocormia subtypes could improve the validity of epidemiological studies and assist future therapeutic trials.

Camptocormia: Etiology, diagnosis, and treatment response

Background

We sought to determine the etiologies, diagnostic testing, and management of a retrospective cohort of patients with camptocormia evaluated at a single center.

Methods

We reviewed medical records of all adult patients evaluated at Mayo Clinic Rochester with a diagnosis of camptocormia from 2000 to 2014. Demographic and clinical data were abstracted and analyzed.

Results

There were 276 patients (58.0% male), with mean age at presentation of 68.6 (±12.7) years. An etiology was identified in 98.2%. The most common etiologies were idiopathic Parkinson disease (22.5%), idiopathic axial myopathy (14.1%), and degenerative joint disease without fixed deformity (13.0%). We also identified several rare causes of camptocormia. Investigations included spine imaging, needle and surface EMG, and muscle biopsy. Most patients received physical therapy and orthotic support with limited benefit. Limited improvement of camptocormia was seen where a treatable etiology was identified.

Conclusions

An etiology can be identified in almost all cases of camptocormia. Most cases are due to 3 common disorders: Parkinson disease, axial myopathy, and degenerative joint disease. A diagnostic and treatment algorithm is proposed.

Managing Gait, Balance, and Posture in Parkinson's Disease

PURPOSE OF REVIEW

Postural instability and gait difficulties inexorably worsen with Parkinson's disease (PD) progression and become treatment resistant, with a severe impact on autonomy and quality of life. We review the main characteristics of balance instability, gait disabilities, and static postural alterations in advanced PD, and the available treatment strategies.

RECENT FINDINGS

It remains very difficult to satisfactorily alleviate gait and postural disturbances in advanced PD. Medical and surgical interventions often fail to provide satisfactory or durable alleviation of these axial symptoms, that may actually call for differential treatments. Exercise and adapted physical activity programs can contribute to improving the patients' condition. Gait, balance, and postural disabilities are often lumped together under the Postural Instability and Gait Difficulties umbrella term. This may lead to sub-optimal patients' management as data suggest that postural, balance, and gait problems might depend on distinct underlying mechanisms. We advocate for a multidisciplinary approach from the day of diagnosis.

Case Studies in Neuroscience: A dissociation of balance and posture demonstrated by camptocormia

Upright stance in humans requires an intricate exchange between the neural mechanisms that control balance and those that control posture; however, the distinction between these control systems is hard to discern in healthy subjects. By studying balance and postural control of a participant with camptocormia - an involuntary flexion of the trunk during standing that resolves when supine - a divergence between balance and postural control was revealed. A kinematic and kinetic investigation of standing and walking showed a stereotyped flexion of the upper body by almost 80° over a few minutes, and yet the participant's ability to control center of mass within the base of support and to compensate for external perturbations remained intact. This unique case also revealed the involvement of automatic, tonic control of the paraspinal muscles during standing and the effects of attention. Although strength was reduced and MRI showed a reduction in muscle mass, there was sufficient strength to maintain an upright posture under voluntary control and when using geste antagoniste maneuvers or "sensory tricks" from visual, auditory, and haptic biofeedback. Dual tasks that either increased or decreased the attention given to postural alignment would decrease or increase the postural flexion, respectively. The custom-made "twister" device that measured axial resistance to slow passive rotation revealed abnormalities in axial muscle tone distribution during standing. The results suggest that the disorder in this case was due to a disruption in the automatic, tonic drive to the postural muscles and that myogenic changes were secondary. NEW & NOTEWORTHY By studying an idiopathic camptocormia case with a detailed biomechanical and sensorimotor approach, we have demonstrated unique insights into the neural control of human bipedalism 1) balance and postural control cannot be considered the same neural process, as there is a stereotyped abnormal flexed posture, without balance deficits, associated with camptocormia, and 2) posture during standing is controlled by automatic axial tone but "sensory tricks" involving sensory biofeedback to direct voluntary attention to postural alignment can override, when required.

Back Extensor Strengthening Exercise and Backpack Wearing Treatment for Camptocormia in Parkinson's Disease: A Retrospective Pilot Study

Objective

To investigate the effect of a conservative treatment regime in Parkinson's disease patients with camptocormia.

Methods

Nine patients with Parkinson's disease were included in a retrospective pilot study of the value of back extensor strengthening exercise. Six inpatients received a 30-minute treatment, twice daily for 5 weeks, being treated on average for 34 days; while three outpatients visited the clinic and were educated for home exercise and backpack wearing treatment. Outpatients should be scheduled to visit the outpatient department to check physical status every 2–4 weeks for an average of 3 months.

Results

All patients except one showed statistically significant improvements in activities of daily living (ADL) and motor symptoms, as measured by flexion angle at standing posture, Unified Parkinson's Disease Rating Scale (UPDRS) II and III, and modified Hoehn-Yahr staging.

Conclusion

Conservative treatment is effective in postural correction of camptocormia in Parkinson's disease, as well as improvement in ADL and motor symptoms.

A case report of thoracolumbar paraspinal myopathy as the cause of camptocormia in a patient with atypical parkinsonism

Background

Camptocormia is severe flexion of the thoracolumbar spine, exaggerated during standing and walking but minimized in supine position. Even though camptocormia is a relatively common condition during the course of Parkinson’s disease, there is ongoing controversy concerning its mechanisms. The most widely accepted and yet still disputed one is dystonia. However, based on myopathic changes observed in the paraspinal muscle biopsies of some PD patients with camptocormia, the attempt to attribute camptocormia to myopathy has continued. This case presents evidence for paraspinal myopathy as the cause of camptocormia in a patient with atypical parkinsonism.

Case presentation

A patient presented with a relatively acute onset of camptocormia and new-onset back pain. Upon examination, she had asymmetric parkinsonism. Magnetic resonance imaging of the lumbar spine revealed alterations in muscle signal intensity in the right paraspinal muscles at the L1–2 level. In the presence of persistent back pain, repeat imaging done two months later showed diffuse enlargement and patchy enhancement of the paraspinal muscles on T1-weighted imaging from T4 through sacrum bilaterally. About fifteen months after the onset of camptocormia, she underwent ultrasound-guided gun biopsy of the paraspinal muscles for evaluation of focal atrophy of the back muscles on the right. The biopsy revealed unmistakable myopathic changes, marked endomysial and perimysial fibrosis of the muscles, and merely mild infiltration of inflammatory cells but no clues regarding the cause of myopathy. On account of persistent back pain and MRI results indicative of ongoing inflammation, she was prescribed glucocorticoid, which she refused to take. Now merely two and a half years after the onset of camptocormia, she is in Hoehn and Yahr stage 4.

Conclusions

The coincidence of back pain with the appearance of camptocormia and the imaging and pathology findings supportive of myopathy give strong evidence for paraspinal myopathy as the cause of the deformity in this patient. When a patient presents with a relatively acute onset of camptocormia accompanied by back pain, the clinician should not overlook the possibility of myopathy of paraspinal muscles, which may be one of the few treatable causes of camptocormia.

Assessment of striatal & postural deformities in patients with Parkinson's disease

BACKGROUND & OBJECTIVES

Though striatal and postural deformities are known to occur commonly in atypical Parkinsonism patients, these may also be seen in patients with Parkinson's disease (PD). These are frequently misdiagnosed as joint or orthopaedic pathology leading to unnecessary investigations. This study was conducted to observe the various striatal and postural deformities among patients with PD in India.

METHODS

This study was conducted at a tertiary care teaching institute in north# India. Seventy consecutive patients with PD diagnosed as per the modified UK Brain Bank criteria were included. Various striatal (hand & foot) and postural (antecollis, camptocormia, scoliosis & Pisa syndrome) deformities and their relation with the duration of disease, severity [measured by the Unified Parkinson's Disease Rating Scale (UPDRS)] and levodopa intake were analyzed.

RESULTS

Of the 70 patients with PD, 34 (48.57%) had either striatal or postural deformities. Striatal foot was the most common deformity observed (25.71%). Camptocormia was the second most common deformity (20%). Striatal and postural deformities were seen in more advanced PD as suggested by significantly higher UPDRS and Hoehn and Yahr scale (P<0.001). Striatal deformities were more ipsilateral to PD symptom onset side (agreement 94.44%). Pisa and scoliosis concavity were more on contralateral side to PD symptoms onset side (66.67%).

INTERPRETATION & CONCLUSIONS

Our results showed that striatal and postural deformities were common and present in about half of the patients with PD. These deformities we more common in patients with advanced stage of PD.

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.

Postural & striatal deformities in Parkinson`s disease: Are these rare?

Parkinson's disease (PD) is the most common neurodegenerative disease and is characterized by tremor, rigidity and akinesia. Diagnosis is clinical in the majority of the patients. Patients with PD may have stooped posture but some of them develop different types of postural and striatal deformities. Usually these deformities are more common in atypical parkinsonian disorders such as progressive supranuclear palsy and multisystem atrophy. But in many studies it has been highlighted that these may also be present in approximately one third of PD patients leading to severe disability. These include antecollis or dropped head, camptocormia, Pisa syndrome, scoliosis, striatal hands and striatal toes. The pathogenesis of these deformities is a complex combination of central and peripheral influences such as rigidity, dystonia and degenerative skeletal changes. Duration of parkinsonism symptoms is an important risk factor and in majority of the patients these deformities are seen in advanced statge of the disease. The patients with such symptoms may initially respond to dopaminergic medications but if not intervened they may become fixed and difficult to treat. Pain and restriction of movement are most common clinical manifestations and these may mimick symptoms of musculoskeletal disorders like rheumatoid arthritis. Early diagnosis is important as the patients may respond to adjustment in dopaminergic medications. Recent advances such as deep brain stimulation (DBS) and ultrasound guided botulinum toxin injection are helpful in management of these deformities in patients with PD.