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Gandolfi M, Geroin C, Imbalzano G, Camozzi S, Menaspà Z, Tinazzi M, Alberto Artusi C. Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions. Clin Park Relat Disord 2024; 10:100240. [PMID: 38596537 PMCID: PMC11002662 DOI: 10.1016/j.prdoa.2024.100240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/21/2023] [Accepted: 01/29/2024] [Indexed: 04/11/2024] Open
Abstract
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.
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Affiliation(s)
- Marialuisa Gandolfi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Neuromotor and Cognitive Rehabilitation Research Centre (CRRNC), University of Verona, Italy
- Neurorehabilitation Unit, AOUI Verona, Italy
| | - Christian Geroin
- Department of Surgery, Dentistry, Paediatric and Gynaecology, University of Verona, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Serena Camozzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Zoe Menaspà
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
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Spindler P, Alzoobi Y, Kühn AA, Faust K, Schneider GH, Vajkoczy P. Deep brain stimulation for Parkinson's disease-related postural abnormalities: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3083-3092. [PMID: 35790655 PMCID: PMC9492622 DOI: 10.1007/s10143-022-01830-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Philipp Spindler
- Department of Neurosurgery, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Yasmin Alzoobi
- Department of Neurosurgery, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea A. Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Spectral analysis of body movement during deep brain stimulation in Parkinson's disease. Gait Posture 2021; 86:217-225. [PMID: 33765547 DOI: 10.1016/j.gaitpost.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 02/15/2021] [Accepted: 03/15/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The characteristics of Parkinson's disease (PD) include postural instability and resting tremor. However, reductions of tremor amplitude do not always improve postural stability. RESEARCH QUESTION What is the effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN) on spectral analysis of body movement in patients with PD when tested without anti-PD medication? The effect of visual cues was also studied. METHODS Ten patients with PD (mean age 64.3 years, range 59-69 years) and 17 control participants (mean age 71.2 years, range 65-79 years) were recruited. Spectral power following a period of quiet stance (35 s) was analysed in three different spectral power bands (0-4 Hz, 4-7 Hz and 7-25 Hz). Motion markers were secured to the head, shoulder, hip, and knee, which recorded movements in two directions, the anteroposterior and lateral. RESULTS DBS STN significantly changed the spectral distribution pattern across the body in the anteroposterior (p = 0.029) and lateral directions (p ≤ 0.003). DBS predominantly reduced spectral power at the head (p ≤ 0.037) and shoulder (p ≤ 0.031) in the lateral direction. The spectral power of the lower and upper body in patients with PD, with DBS ON, were more similar to the control group, than to DBS OFF. Visual cues mainly reduced spectral power in the anteroposterior direction at the shoulder (p ≤ 0.041) in controls and in patients with PD with DBS ON. SIGNIFICANCE There is an altered postural strategy in patients with PD with DBS ON as shown by an altered spectral power distribution pattern across body segments and a reduction of spectral power in the lateral direction at the head and shoulder. A reduction of spectral power in controls and in patients with PD with DBS ON suggests that visual cues are able to reduce spectral power to some extent, but not with DBS OFF where postural sway and power are larger.
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Schlenstedt C, Gavriliuc O, Boße K, Wolke R, Granert O, Deuschl G, Margraf NG. The Effect of Medication and Deep Brain Stimulation on Posture in Parkinson's Disease. Front Neurol 2019; 10:1254. [PMID: 31849818 PMCID: PMC6901659 DOI: 10.3389/fneur.2019.01254] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Olga Gavriliuc
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany.,Department of Neurology, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova
| | - Kathrin Boße
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
| | - Robin Wolke
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
| | - Oliver Granert
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
| | - Günther Deuschl
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
| | - Nils G Margraf
- Department of Neurology, UKSH, Christian-Albrechts-University, Kiel, Germany
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Lizarraga KJ, Fasano A. Effects of Deep Brain Stimulation on Postural Trunk Deformities: A Systematic Review. Mov Disord Clin Pract 2019; 6:627-638. [PMID: 31745470 DOI: 10.1002/mdc3.12829] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/07/2019] [Accepted: 07/19/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Karlo J Lizarraga
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and Division of Neurology, Department of Medicine University of Toronto Toronto Ontario Canada.,Motor Physiology and Neuromodulation Program, Division of Movement Disorders, Department of Neurology University of Rochester Rochester New York USA.,Center for Health and Technology (CHeT) University of Rochester Rochester New York USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and Division of Neurology, Department of Medicine University of Toronto Toronto Ontario Canada.,Krembil Research Institute Toronto Ontario Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA) Toronto Ontario Canada
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Horisawa S, Oka M, Kohara K, Kawamata T, Taira T. Staged bilateral pallidotomy for dystonic camptocormia: case report. J Neurosurg 2019; 131:839-842. [PMID: 30497197 DOI: 10.3171/2018.5.jns1840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
Camptocormia is a rare, involuntary movement disorder, presenting as truncal flexion while standing or walking, and is mainly observed as a feature of Parkinson's disease (PD) and primary dystonia. Deep brain stimulation (DBS) of the globus pallidus internus is effective for refractory camptocormia observed with PD or dystonia. However, the effectiveness of pallidotomy for camptocormia has not been investigated. The authors report the case of a 38-year-old man with anterior truncal bending that developed when he was 36 years old. Prior to the onset of the symptom, he had been taking antipsychotic drugs for schizophrenia. There were no features of PD; the symptom severely interfered with his walking and daily life. He was given anticholinergics, clonazepam, and botulinum toxin injections, which did not result in much success. Because of the patient's unwillingness to undergo implantation of a hardware device, he underwent staged bilateral pallidotomy with complete resolution for a diagnosis of tardive dystonic camptocormia. The Burke-Fahn-Marsden dystonia rating scale subscore for the trunk before and after bilateral pallidotomy was 3 and 0, respectively. No perioperative adverse events were observed. Effects have persisted for 18 months. Bilateral pallidotomy can be a treatment option for medically refractory dystonic camptocormia without the need for device implantation.
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Chan AK, Chan AY, Lau D, Durcanova B, Miller CA, Larson PS, Starr PA, Mummaneni PV. Surgical management of camptocormia in Parkinson's disease: systematic review and meta-analysis. J Neurosurg 2019; 131:368-375. [PMID: 30215560 DOI: 10.3171/2018.4.jns173032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/02/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Camptocormia is a potentially debilitating condition in the progression of Parkinson's disease (PD). It is described as an abnormal forward flexion while standing that resolves when lying supine. Although the condition is relatively common, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, the authors systematically reviewed the current surgical management strategies for camptocormia. METHODS PubMed was queried for primary studies involving surgical intervention for camptocormia in PD patients. Studies were excluded if they described nonsurgical interventions, provided only descriptive data, or were case reports. Secondarily, data from studies describing deep brain stimulation (DBS) to the subthalamic nuclei were extracted for potential meta-analysis. Variables showing correlation to improvement in sagittal plane bending angle (i.e., the vertical angle caused by excessive kyphosis) were subjected to formal meta-analysis. RESULTS The query resulted in 9 studies detailing treatment of camptocormia: 1 study described repetitive trans-spinal magnetic stimulation (rTSMS), 7 studies described DBS, and 1 study described deformity surgery. Five studies were included for meta-analysis. The total number of patients was 66. The percentage of patients with over 50% decrease in sagittal plane imbalance with DBS was 36.4%. A duration of camptocormia of 2 years or less was predictive of better outcomes (OR 4.15). CONCLUSIONS Surgical options include transient, external spinal stimulation; DBS targeting the subthalamic nuclei; and spinal deformity surgery. Benefit from DBS stimulation was inconsistent. Spine surgery corrected spinal imbalance but was associated with a high complication rate.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Alvin Y Chan
- 2Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Darryl Lau
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Beata Durcanova
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Catherine A Miller
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Paul S Larson
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Philip A Starr
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and
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Roediger J, Artusi CA, Romagnolo A, Boyne P, Zibetti M, Lopiano L, Espay AJ, Fasano A, Merola A. Effect of subthalamic deep brain stimulation on posture in Parkinson's disease: A blind computerized analysis. Parkinsonism Relat Disord 2019; 62:122-127. [PMID: 30638820 DOI: 10.1016/j.parkreldis.2019.01.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We sought to assess the effect of subthalamic deep brain stimulation (STN DBS) on Parkinson's disease (PD)-associated postural abnormalities. METHODS A computerized analysis of posture was used to quantify the thoracolumbar, thoracic, and cervical-occipital ventral angles, as well as the thoracolumbar and cervical-occipital lateral angles from the video-repository of three specialized movement disorder centers (n = 158 patients). Data was extracted from frames from video-recordings in the pre-surgical medication-ON (dopaminergic therapy) and post-surgical stimulation-ON/medication-ON states (STN DBS plus dopaminergic therapy). The sum of the five postural angles (global postural angle) was used to compare pre-vs. post-surgical trunk posture alterations. A multivariate analysis was used to examine the association between changes in the postural angles and demographic or clinical variables. RESULTS There was a 6.7% amelioration in the global postural angle between the pre- and post-surgical assessments (p = 0.031). Motor response to and pre-surgical dosage of levodopa, male gender, and shorter PD duration were identified as predictors for posture improvement after STN DBS. Cases meeting criteria for lower (n = 2) or upper (n = 1) camptocormia respectively improved by 48.1% in the ventral thoracolumbar angle (from 36.4 ± 0.0° to 18.9 ± 4.2°) and 13.8% in the ventral thoracic angle (from 49.1° to 42.3°). Cases meeting criteria for Pisa syndrome (n = 2) improved by 67.5% in the lateral thoracolumbar angle (from 16.9 ± 2.0° to 5.5 ± 4.7°). CONCLUSIONS STN DBS has a relatively small but significant effect on PD-associated postural abnormalities, potentially enhancing the effect of dopaminergic medications alone.
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Affiliation(s)
- Jan Roediger
- Department of Neurology, University Hospital of Cologne, Germany
| | - Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, via Cherasco 15, 10124, Torino, Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, via Cherasco 15, 10124, Torino, Italy
| | - Pierce Boyne
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, via Cherasco 15, 10124, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, via Cherasco 15, 10124, Torino, Italy
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada.
| | - Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
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Rossi M, Bruno V, Arena J, Cammarota Á, Merello M. Challenges in PD Patient Management After DBS: A Pragmatic Review. Mov Disord Clin Pract 2018; 5:246-254. [PMID: 30363375 PMCID: PMC6174419 DOI: 10.1002/mdc3.12592] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 01/01/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) or internal globus pallidus (GPi) represents an effective and universally applied therapy for Parkinson's disease (PD) motor complications. However, certain procedure-related problems and unrealistic patient expectations may detract specialists from indicating DBS more widely despite significant clinical effects. METHODS This review provides a pragmatic educational summary of the most conflicting postoperative management issues in patients undergoing DBS for PD. RESULTS DBS in PD has been associated with certain complications and post-procedural management issues, which can complicate surgical outcome interpretation. Many PD patients consider DBS outcomes negative due to unfulfilled expectations, even when significant motor symptom improvement is achieved. Speech, gait, postural stability, and cognition may worsen after DBS and body weight may increase. Although DBS may induce impulse control disorders in some cases, in others, it may actually improve them when dopamine agonist dosage is reduced after surgery. However, apathy may also arise, especially when dopaminergic medication tapering is rapid. Gradual loss of response with time suggests disease progression, rather than the wearing off of DBS effects. Furthermore, implantable pulse generator expiration is considered a movement disorder emergency, as it may worsen parkinsonian symptoms or cause life-threatening akinetic crises due to malignant DBS withdrawal syndrome. CONCLUSION Major unsolved issues occurring after DBS therapy preclude complete patient satisfaction. Multidisciplinary management at experienced centers, as well as careful and comprehensive delivery of information to patients, should contribute to make DBS outcome expectations more realistic and allow post procedural complications to be better accepted.
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Affiliation(s)
- Malco Rossi
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Verónica Bruno
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
- Argentine National Scientific and Technological Research Council (CONICET)Buenos AiresArgentina
| | - Julieta Arena
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Ángel Cammarota
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Marcelo Merello
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
- Argentine National Scientific and Technological Research Council (CONICET)Buenos AiresArgentina
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Lee KH, Kim JM, Kim HS. Back Extensor Strengthening Exercise and Backpack Wearing Treatment for Camptocormia in Parkinson's Disease: A Retrospective Pilot Study. Ann Rehabil Med 2017; 41:677-685. [PMID: 28971053 PMCID: PMC5608676 DOI: 10.5535/arm.2017.41.4.677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/04/2016] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Kun Hee Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Moon Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyoung Seop Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Yamada K, Shinojima N, Hamasaki T, Kuratsu JI. Subthalamic nucleus stimulation improves Parkinson's disease-associated camptocormia in parallel to its preoperative levodopa responsiveness. J Neurol Neurosurg Psychiatry 2016; 87:703-9. [PMID: 26424897 DOI: 10.1136/jnnp-2015-310926] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 08/10/2015] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Kazumichi Yamada
- Department of Functional Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Naoki Shinojima
- Department of Functional Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadashi Hamasaki
- Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Jun-Ichi Kuratsu
- Department of Neurosurgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
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Margraf N, Wrede A, Deuschl G, Schulz-Schaeffer W. Pathophysiological Concepts and Treatment of Camptocormia. JOURNAL OF PARKINSON'S DISEASE 2016; 6:485-501. [PMID: 27314757 PMCID: PMC5008234 DOI: 10.3233/jpd-160836] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- N.G. Margraf
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - A. Wrede
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - G. Deuschl
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Srivanitchapoom P, Hallett M. Camptocormia in Parkinson's disease: definition, epidemiology, pathogenesis and treatment modalities. J Neurol Neurosurg Psychiatry 2016; 87:75-85. [PMID: 25896683 PMCID: PMC5582594 DOI: 10.1136/jnnp-2014-310049] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/30/2015] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Prachaya Srivanitchapoom
- Faculty of Medicine, Division of Neurology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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Ha Y, Oh JK, Smith JS, Ailon T, Fehlings MG, Shaffrey CI, Ames CP. Impact of Movement Disorders on Management of Spinal Deformity in the Elderly. Neurosurgery 2015; 77 Suppl 4:S173-85. [DOI: 10.1227/neu.0000000000000940] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Therapy-resistant symptoms in Parkinson’s disease. J Neural Transm (Vienna) 2015; 123:19-30. [DOI: 10.1007/s00702-015-1463-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/15/2015] [Indexed: 12/25/2022]
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Margraf NG, Rohr A, Granert O, Hampel J, Drews A, Deuschl G. MRI of lumbar trunk muscles in patients with Parkinson’s disease and camptocormia. J Neurol 2015; 262:1655-64. [DOI: 10.1007/s00415-015-7726-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
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Schulz-Schaeffer WJ, Margraf NG, Munser S, Wrede A, Buhmann C, Deuschl G, Oehlwein C. Effect of neurostimulation on camptocormia in Parkinson's disease depends on symptom duration. Mov Disord 2015; 30:368-72. [PMID: 25678310 PMCID: PMC5132064 DOI: 10.1002/mds.26081] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 10/06/2014] [Accepted: 10/12/2014] [Indexed: 11/10/2022] Open
Abstract
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
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Affiliation(s)
- Walter J Schulz-Schaeffer
- Prion and Dementia Research Unit, Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
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Fasano A, Aquino CC, Krauss JK, Honey CR, Bloem BR. Axial disability and deep brain stimulation in patients with Parkinson disease. NATURE REVIEWS. NEUROLOGY 2015. [PMID: 25582445 DOI: 10.1038/nrneurol.2014.252.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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Affiliation(s)
- Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Camila C Aquino
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Straße 1, 30625 Hannover, Germany
| | - Christopher R Honey
- Division of Neurosurgery at the University of British Columbia, 8105-2775 Laurel Street, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, PO Box 9101, 6500 HB Nijmegen, Netherlands
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Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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