Lateral flexion in Parkinson’s disease and Pisa syndrome

Abstract

Various types of abnormal posture are observed in Parkinson's disease (PD). Lateral flexion is very common and frequent among them. The clinical characteristics of lateral flexion in PD vary and are classified into two types, the chronic and subchronic types. The chronic type of lateral flexion in PD appears subclinically and worsens, which is related to the laterality of parkinsonian symptoms and the progression of the disease. The subchronic type of lateral flexion in PD develops subacutely and worsens rapidly in several months. An atypical and rare type of tonic truncal dystonia, Pisa syndrome, may be induced following the intake of neuroleptics. The clinical features of the subchronic type of lateral flexion in PD are similar to those of Pisa syndrome. Differences between lateral flexion in PD and Pisa syndrome are described.

Mood and behavioural effects of subthalamic stimulation in Parkinson's disease

“…Interestingly, a second subthalamotomy contralateral to the first surgery, which reduced the asymmetry of parkinsonian signs, also corrected the postural deviation in the two cases described by Su et al 40 The involvement of the dopaminergic system in the pathogenesis of Pisa syndrome is supported by the description of its occurrence after neuroleptic, that is, dopaminergic antagonist, exposure. 13,14 Moreover, in PD the introduction, increase, or reduction of dopaminergic medication can induce or reverse Pisa syndrome, 19,23 reinforcing the hypothesis that asymmetry in the functioning of basal ganglia loop might contribute to the development of the syndrome. The addition of a dopaminergic drug might therefore alter the balance between the two striata, leading to a lateral deviation resulting from an increased response in the sensitized, more denervated, striatum, as described in animal models.…”

“…In such instances, progression is slow, and identification of causative factors is not possible. 23 In our experience, the tilt is sometimes first visible when sitting in this latter category of patient. With time, trunk deviation also persists when standing and walking.…”

“…This could explain why parkinsonian patients with moderate Pisa syndrome perceive themselves as standing up straight, and feel as if they are leaning to the contralateral side when corrected. 9,23 Alterations in perception of postural verticality have been reported in PD patients. Proctor and colleagues 65 assessed 38 PD patients undergoing unilateral thalamotomy before and after surgery.…”

Pisa syndrome in Parkinson's disease: diagnostic and management challenges

“…15,54,55 Early recognition of PS represents mainstay of the treatment because chronic forms are often resistant to therapy. Most of the PD patients with PS are not aware of lateral trunk deviation in the early stage.…”

Botulinum Toxin Type A and Physiokinesiterapy in the Treatment of Pisa Syndrome

“…PS has been described among symptoms of tardive neuroleptic dystonia, in patients with dementia treated with cholinesterase inhibitors, in patients with idiopathic primary dystonia, in patients with Parkinson's disease (PD), Alzheimer's disease, and multiple system atrophy [ 1-7. ] The initial development of lateral flexion in PD is subclinical but its progression is rapid and it is caused by a component of dystonia added to rigidity [8][9][10]. The pathophysiology is not fully understood.…”