Pisa Syndrome

Pisa Syndrome

1. Pisa Syndrome Ade Wijaya, MD – December 2018

2. Introduction Pisa syndrome was first described in 1972 in patients treated with neuroleptics Since 2003, when it was first reported in patients with Parkinson’s disease (PD) Prevalence: 8.8 % in PD patients Ekbom K, Lindholm H, Ljungberg L. New dystonic syndrome associated with butyrophenone therapy. Z Neurol 1972;202:94- 103 . Tinazzi M, Fasano A, Geroin C, et al. Italian Pisa Syndrome Study Group. Pisa syndrome in Parkinson disease: an observational multicenter Italian study. Neurology 2015;85:1769-1779.

3. Introduction Lateral deviation of the spine with a corresponding tendency to lean to one side “The scoliosis of parkinsonism ” Pisa syndrome is a potentially reversible condition , early recognition and management is crucial to limit the development of structural deformities that can cause severe and irreversible mechanical constraints affecting respiration, mobility, and postural stability Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. Lancet Neurol 2011; 10: 538–49. Kashihara K, Imamura T. Clinical correlates of anterior and lateral flexion of the thoracolumbar spine and dropped head in patients with Parkinson’s disease. Parkinsonism Relat Disord 2012; 18: 290–93. Sicard JA, Alquier L. Les deviations de la colonne vertebrale dans la maladie de Parkinson. Nouvelle Iconographie de la Salpetriere 1905; 16: 377–84. Duvoisin RC, Marsden CD. Note on the scoliosis of Parkinsonism. J Neurol Neurosurg Psychiatry 1975; 38: 787–93.

4. Definition A pronounced lateral flexion of greater than 10 ° while standing, which can be almost completely reversed by passive mobilisation or supine positioning Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. Lancet Neurol 2011; 10: 538–49.

5. Other Posture Deformities in Parkinson’s Disease and Parkinsonism Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. Lancet Neurol 2011; 10: 538–49.

6. Associated Conditions Tinazzi M, Geroin C, Gandolfi M, Smania N, Tamburin S, Morgante F, Fasano A. Pisa syndrome in Parkinson's disease: An integrated approach from pathophysiology to management. Movement Disorders. 2016 Dec;31(12):1785-95.

7. Clinical Features Subtle onset and gradual progression VS acute onset followed by rapid worsening over months Acute (< 1 month), subchronic (≥1 month to <3 months ), and chronic (≥3 months ) Drug-induced Pisa syndrome (dopaminergic) Barone P, Santangelo G, Amboni M, Pellecchia MT, Vitale C. Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment. The Lancet Neurology. 2016 Sep 1;15(10):1063-74.

8. Risk Factors Older age Longer disease duration More severe disease by H&Y Osteoporosis and/or arthrosis Male Tinazzi M, Fasano A, Geroin C, et al, and the Italian Pisa Syndrome Study Group. Pisa syndrome in Parkinson disease: An observational multicenter Italian study. Neurology 2015; 85: 1769–79. Vitale C, Falco F, Trojano L, et al. Neuropsychological correlates of Pisa syndrome in patients with Parkinson’s disease. Acta Neurol Scand 2015; published online Oct 2. Kashihara K, Imamura T. Clinical correlates of anterior and lateral flexion of the thoracolumbar spine and dropped head in patients with Parkinson’s disease. Parkinsonism Relat Disord 2012; 18: 290–93.

9. Pathophysiology Central mechanisms refer to: Basal ganglia dysfunction Abnormal sensorimotor integration Cognitive dysfunctions affecting the body schema perception and postural control Peripheral mechanisms refer to alterations of the musculoskeletal system such as myopathy and degenerative spinal and soft tissue changes Geroin C, Smania N, Schena F, et al. Does the Pisa syndrome affect postural control, balance, and gait in patients with Parkinson’s disease? An observational cross-sectional study. Parkinsonism Relat Disord 2015;21:736-741. Vitale C, Falco F, Trojano L, et al. Neuropsychological correlates of Pisa syndrome in patients with Parkinson’s disease. Acta Neurol Scand 2016;134:101-107. Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. Lancet Neurol 2011;10:538-549.

10. Pathophysiology NORMAL PISA SYNDROME Shumway-Cook A, Woollacott M. Attentional demands and postural control: the eff ect of sensory context. J Gerontol A Biol Sci Med Sci 2000; 55: M10–16. Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing 2006; 35 (suppl 2) : ii7–11. Borel L, Alescio-Lautier B. Posture and cognition in the elderly: interaction and contribution to the rehabilitation strategies. Neurophysiol Clin 2014; 44: 95–107.

11. Diagnosis Barone P, Santangelo G, Amboni M, Pellecchia MT, Vitale C. Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment. The Lancet Neurology. 2016 Sep 1;15(10):1063-74.

12. Treatment Barone P, Santangelo G, Amboni M, Pellecchia MT, Vitale C. Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment. The Lancet Neurology. 2016 Sep 1;15(10):1063-74.

13. Management Barone P, Santangelo G, Amboni M, Pellecchia MT, Vitale C. Pisa syndrome in Parkinson's disease and parkinsonism: clinical features, pathophysiology, and treatment. The Lancet Neurology. 2016 Sep 1;15(10):1063-74.

14. Summary Pisa Syndrome associated with many medical conditions, especially Parkinson’s Disease / Parkinsonism Central & Peripheral mechanism Multiprofessional management