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

Abstract

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.

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

“…However, we hypothesize that trunk asymmetry related to LTB may reduce trunk mobility more than FTB, leading to a greater impairment in motor functions, and intrinsic gender differences of the anatomy of the spine (24) may be a predisposing factor, along with subclinical osteoporosis for which the frequency in women is more than double that in men (25). PD-associated postural abnormalities have attracted increasing attention from clinicians and researchers since they were recognized as a frequent and disabling complication of PD (1,(3)(4)(5)(6)26). Most studies on severe forward and lateral trunk flexion (i.e., CC, PS, and AC) to date have applied arbitrary and often diverse diagnostic criteria (2,3).…”

“…Most studies on severe forward and lateral trunk flexion (i.e., CC, PS, and AC) to date have applied arbitrary and often diverse diagnostic criteria (2,3). Despite the different criteria employed, greater disability is noted in patients with CC, PS, and AC than in those without severe postural abnormalities (1). Moreover, patients with lower CC seem to have more severe gait and postural control impairment than those with upper CC and without CC (26).…”

“…These limitations notwithstanding, our findings indicate that advanced stage of disease and longer disease duration, but not the degree of trunk bending, may explain the greater disability of PD patients with postural abnormalities. Limitation in ADLs and presence history of falls and severe pain in FTB, LTB, and FNB may be more closely related to PD phenotype and progression than trunk flexion itself (1,5). In contrast, moderate/severe motor impairment can be predicted by a degree of LTB > 10 • , which is the cut-off typically used for the diagnosis of PS.…”

“…Three main types of PD-associated postural abnormalities are distinguished: camptocormia (CC), defined as an involuntary forward trunk bending (FTB) appearing during standing or walking and resolving in a supine position of at least 30 • at the lumbar fulcrum and/or at least 45 • at the thoracic fulcrum (2); Pisa syndrome (PS), defined as a sustained lateral trunk bending (LTB) of at least 10 • worsened by prolonged sitting or walking (3); and anterocollis (AC), defined as an involuntary forward neck bending (FNB) of at least 45 • (3). PD studies investigating CC, PS, and AC report greater disability in patients with postural abnormalities and a higher risk of falls, back pain, and worse quality of life (1,(3)(4)(5)(6).…”

“…Postural abnormalities are common features of Parkinson's disease (PD) and manifest in over 20% of patients during the course of disease (1). Three main types of PD-associated postural abnormalities are distinguished: camptocormia (CC), defined as an involuntary forward trunk bending (FTB) appearing during standing or walking and resolving in a supine position of at least 30 • at the lumbar fulcrum and/or at least 45 • at the thoracic fulcrum (2); Pisa syndrome (PS), defined as a sustained lateral trunk bending (LTB) of at least 10 • worsened by prolonged sitting or walking (3); and anterocollis (AC), defined as an involuntary forward neck bending (FNB) of at least 45 • (3).…”