Axial Postural Abnormalities in Parkinsonism: Gaps in Predictors, Pathophysiology, and Management

Abstract

Axial postural abnormalities are common and disabling motor complications of Parkinson's disease (PD) and parkinsonism. They consist of abnormal trunk or neck postures in the upright position, often interfering with daily life activities.1-5

A high number of patients with PD may develop one or more axial postural abnormalities, which may begin as minor forms, almost universal in persons with parkinsonism (eg, minor flexed posture of the trunk and lower limbs), and progress to severe forms such as camptocormia, antecollis, or Pisa syndrome in over 20% of patients,1 although the definitions of severe axial postural abnormalities were purely based on subjective/expert opinion. Drug-induced parkinsonism or progressive supranuclear palsy may also present axial postural abnormalities, and in multiple system atrophy these symptoms are more frequent than in PD and occur earlier in the disease course.2, 6 Because axial postural abnormalities are associated with an increased risk of falling, pain, and diminished quality of life, their proper prevention and management is warranted.2, 4, 5, 7, 8 However, to date, recommendations for multidisciplinary management and prevention remain an unmet need.3 Diagnosis is typically based on a simple clinical examination, whereas treatments (eg, pharmacological, physical therapy, and surgical treatments) have been evaluated only in small single-center studies that failed to show consistent, long-lasting improvement.2, 5, 8-10 The absence of reliable protocols for the assessment, treatment, and prevention of axial postural abnormalities in parkinsonism is probably due to the largely obscure pathophysiology and uncertainty about prognostic factors needed to estimate beneficial responses to therapy (eg, duration of axial postural abnormalities).2, 5, 8, 11-13 The aim of this viewpoint is to critically analyze the literature on axial postural abnormalities, identify the current issues and gaps, and formulate proposals for current clinical management and future research exploration.