Efficacy of a combined therapeutic approach in the management of Pisa Syndrome

Martino, Siria Di; Unti, Elisa; Tramonti, Caterina; Mazzucchi, Sonia; Bonuccelli, Ubaldo; Rossi, Bruno; Ceravolo, Roberto; Chisari, Carmelo

doi:10.3233/nre-171478

Cited by 6 publications

(15 citation statements)

References 15 publications

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“…In favor of dystonic etiology, several EMG investigations have reported tonic activation of paraspinal or abdominal muscles ipsilateral to the leaning side in PD patients with PS 4 – 6 , 20 , 34 . However, this pattern was not observed in our PD-PS.…”

Section: Discussionmentioning

confidence: 99%

“…These contradictory findings might reflect methodological variability, including muscles explored and EMG recording paradigm, or different patient characteristics, such as disease severity and duration of PS. Indeed, we did not specifically examine EMG activity of the abdominal muscles, such as the external oblique, which are a potential target of lidocaine injection therapy to ameliorate PS 34 . Nevertheless, there have been arguments against dystonic hypothesis, due to a paucity of clinical features compatible with dystonia in PS, including overflow, twisting or twitching, and aggravation with motion 1 , 2 .…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, a recent series demonstrated that only a small number of PD patients with PS improved their postural deformities using sensory tricks that typically ameliorate dystonia 14 . Nevertheless, some PD patients with PS have reported beneficial effects of botulinum toxin or lidocaine injections, which relieve dystonic contraction of paraspinal or external oblique muscles 20 , 34 , 35 . Further investigations using a unified EMG protocol in a large population of PD patients with PS are required to clarify this issue.…”

Section: Discussionmentioning

confidence: 99%

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Pisa Syndrome in Parkinson’s Disease: Pathogenic Roles of Verticality Perception Deficits

Huh

Kim

Chung

et al. 2018

Sci Rep

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We elucidated whether verticality misperception is associated with the generation of Pisa syndrome (PS) in patients with Parkinson’s disease (PD). To examine the heterogenous influence of verticality perception, we also identified the characteristics distinguishing between PD patients with PS who tilted toward the deviation of perceived verticality and those who did not. Subjective visual vertical (SVV) testing was performed in 54 PD patients with PS and 36 without PS to measure verticality perception. Other potential risk factors for PS were evaluated by assessing the asymmetry of motor symptoms, EMG activities of paraspinal muscles, bithermal caloric tests, back pain history, and Berg Balance Scale. Abnormal SVV (odds ratio (OR) 18.40, p = 0.006), postural imbalance (OR 0.71, p = 0.046), and unilateral EMG hyperactivity of paraspinal muscles (OR 39.62, p = 0.027) were independent contributors to PS. In subgroup analysis, EMG hyperactivity of paraspinal muscles contralateral to the leaning side and postural imbalance were associated with PD patients with PS who tilted toward the SVV deviation, whereas back pain was more frequent in those who did not. Verticality misperception is a potent risk factor for PS in PD and contributes differentially to PS depending on the congruence between its direction and PS direction, indicating distinct pathogenic roles.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Pisa Syndrome in Parkinson’s Disease: Pathogenic Roles of Verticality Perception Deficits

Huh

Kim

Chung

et al. 2018

Sci Rep

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“…Only six studies were specifically designed to test the efficacy of non-invasive therapies (neurorehabilitation, botulinum toxin, or lidocaine injections) in patients with PS and PD ( 2 , 7 , 8 , 40 – 42 ), and among these only two were randomized controlled trials ( 2 , 40 ). Three studies used a kinematic analysis of movement for recording the outcome measures ( 2 , 7 , 41 ), but only two of them evaluated trunk ROM during dynamic tasks ( 2 , 7 ). The improvement achieved in our t-DCS group is consistent with previous data reporting a reduction between 30 and 50% of lateral trunk inclination and a comparable increase of ROM of trunk bending at the end of a rehabilitation program ( 2 , 7 , 8 , 40 – 42 ).…”

Section: Discussionmentioning

confidence: 99%

Non-Invasive Neuromodulation in the Rehabilitation of Pisa Syndrome in Parkinson's Disease: A Randomized Controlled Trial

Icco

Putortì

Allena³

et al. 2022

Front. Neurol.

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BackgroundPisa syndrome (PS) is a frequent postural complication of Parkinson's disease (PD). PS poorly responds to anti-parkinsonian drugs and the improvement achieved with neurorehabilitation tends to fade in 6 months or less. Transcranial direct current stimulation (t-DCS) is a non-invasive neuromodulation technique that showed promising results in improving specific symptoms in different movement disorders.ObjectivesThis study aimed to evaluate the role of bi-hemispheric t-DCS as an add-on to a standardized hospital rehabilitation program in the management of PS in PD.MethodsThis study included 28 patients with PD and PS (21 men, aged 72.9 ± 5.1 years) who underwent a 4-week intensive neurorehabilitation treatment and were randomized to receive: i) t-DCS (t-DCS group, n = 13) for 5 daily sessions (20 min−2 mA) with bi-hemispheric stimulation over the primary motor cortex (M1), or ii) sham stimulation (sham group, n = 15) with the same duration and cadence. At baseline (T0), end of rehabilitation (T1), and 6 months later (T2) patients were evaluated with both trunk kinematic analysis and clinical scales, including UPDRS-III, Functional Independence Measure (FIM), and Numerical Rating Scale for lumbar pain.ResultsWhen compared to the sham group, the t-DCS group achieved a more pronounced improvement in several variables: overall posture (p = 0.014), lateral trunk inclination (p = 0.013) during upright standing position, total range of motion of the trunk (p = 0.012), FIM score (p = 0.048), and lumbar pain intensity (p = 0.017).ConclusionsOur data support the use of neuromodulation with t-DCS as an add-on to neurorehabilitation for the treatment of patients affected by PS in PD.

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“…The main study limitations were pitfalls in study design, small sample size, different diagnostic criteria to define axial postural abnormalities, and use of one or more different measurement methods: standard goniometric measurement with a wall goniometer, smartphone, protractor, inclinometer or photographs was used in 22 studies, 40,47,48,50,51,57,58,[60][61][62][63][64][65][66]72,73,77,78,81,82,98,101 software-based measurement with NeuroPostureApp, Kinovea, MB Ruler ® software, or Image J was used in 12, [37][38][39]41,[44][45][46]49,51,52,56,97,99 Cobb angle, X-ray in nine, 42,43,55,71,79,81,[83][84][85] a spinal mouse electronic measuring device in one study 91 ; 26 studies reported no instrument, tool or bony reference points for evaluating axial postural abnormalities. 53,...…”

Section: Pathophysiology: Main Findingsmentioning

confidence: 99%

Predictors and Pathophysiology of Axial Postural Abnormalities in Parkinsonism: A Scoping Review

Artusi,

Geroin,

Nonnekes

et al. 2023

Movement Disord Clin Pract

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BackgroundPostural abnormalities involving the trunk are referred to as axial postural abnormalities and can be observed in over 20% of patients with Parkinson disease (PD) and in atypical parkinsonism. These symptoms are highly disabling and frequently associated with back pain and a worse quality of life in PD. Despite their frequency, little is known about the pathophysiology of these symptoms and scant data are reported about their clinical predictors, making it difficult to prompt prevention strategies.ObjectivesWe conducted a scoping literature review of clinical predictors and pathophysiology of axial postural abnormalities in patients with parkinsonism to identify key concepts, theories and evidence on this topic.MethodsWe applied a systematic approach to identify studies, appraise quality of evidence, summarize main findings, and highlight knowledge gaps.ResultsNinety‐two articles were reviewed: 25% reported on clinical predictors and 75% on pathophysiology. Most studies identified advanced disease stage and greater motor symptoms severity as independent clinical predictors in both PD and multiple system atrophy. Discrepant pathophysiology data suggested different potential central and peripheral pathogenic mechanisms.ConclusionsThe recognition of clinical predictors and pathophysiology of axial postural abnormalities in parkinsonism is far from being elucidated due to literature bias, encompassing different inclusion criteria and measurement tools and heterogeneity of patient samples. Most studies identified advanced disease stage and higher burden of motor symptoms as possible clinical predictors. Pathophysiology data point towards many different (possibly non‐mutually exclusive) mechanisms, including dystonia, rigidity, proprioceptive and vestibular impairment, and higher cognitive deficits.This article is protected by copyright. All rights reserved.

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Efficacy of a combined therapeutic approach in the management of Pisa Syndrome

Abstract: These data highlight the need for accurate characterization of PS focusing on the role of abdominal muscles and the need for a specific rehabilitation protocol for PS management.

Cited by 6 publications

References 15 publications

Pisa Syndrome in Parkinson’s Disease: Pathogenic Roles of Verticality Perception Deficits

Pisa Syndrome in Parkinson’s Disease: Pathogenic Roles of Verticality Perception Deficits

Non-Invasive Neuromodulation in the Rehabilitation of Pisa Syndrome in Parkinson's Disease: A Randomized Controlled Trial

Predictors and Pathophysiology of Axial Postural Abnormalities in Parkinsonism: A Scoping Review

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