Lateral trunk flexion and Pisa syndrome in Parkinson's disease. Are they really always different conditions although denoting similar features?

Context: Pisa Syndrome (PS) is a rare postural disorder, characterized by dystonia of the trunk muscles, lateral deviation as well as rotation of the axial axis. There is a strong association with Parkinson’s disease (PD) due to the possible imbalance between neurotransmitters. It happens either due to a decrease in dopaminergic stimuli, either because of an excess of cholinergic stimuli or drugs (an example of antidopaminergics). The diagnosis is clinical, showing at least a 10-degree trunk flexion with improvement of pharmacological and non- pharmacological measures. Case report: A 60-year-old man was diagnosed with PD five years ago due to tipical clinical complaints and physical examination. The treatment recquired an increase of Pramipexole as well as the use of Levodopa and Benserazide. After two years, he complained about neck pain, low back pain, hip pain and a slight trunk twisting. After six months, his pain was worse and he reported right hemidystonia. Thus, he was diagnosed with PS associated with PD. It was decided to optimize the therapy with Pregabalin, muscle relaxants and rehabilitation. However, it did not show any good result. In 2020, the application of botulinum toxin (BTX) evidenced excellent results, improving both the pain and the spasticity of the patient. Conclusions: Early recognition is necessary to introduce the right treatment as soon as possible, especially BTX and rehabilitation, ensuring functionality and avoiding negative outcomes.

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Use of Botulinum Neurotoxin in Parkinson’s Disease: A Critical Appraisal

Toxins ◽

10.3390/toxins13020087 ◽

2021 ◽

Vol 13 (2) ◽

pp. 87

Author(s):

Wolfgang H. Jost

Keyword(s):

Parkinson’S Disease ◽

Parkinson's Disease ◽

Botulinum Neurotoxin ◽

Critical Appraisal ◽

Freezing Of Gait ◽

Sufficient Data ◽

Pisa Syndrome ◽

Focal Hyperhidrosis ◽

Detrusor Hyperactivity ◽

Important Indication

For well over 30 years, the botulinum neurotoxin (BoNT) has been used for a large number of indications, some of which however have not been licensed. Admittedly, approval varies in many countries and this permits a large spectrum for evaluation. Thus, BoNT is used for patients with Parkinson’s disease (PD) and other Parkinson’s syndromes (PS) in varying degrees of frequency. We have to distinguish between (1) indications that are either approved or (2) those not approved, (3) indications that might be a result of PS and (4) finally those which appear independent of PS. The most important indication for BoNT in PS patients is probably sialorrhea, for which approval has been granted in the majority of countries. Cervical dystonia is a frequent symptom in PS, with anterocollis as a specific entity. A further indication is blepharospasm in the different forms, especially the inhibition of eyelid opening in atypical PS. The use of BoNT in cases of camptocormia, the Pisa syndrome and neck rigidity is still a matter of debate. In dystonia of the extremities BoNT can be recommended, especially in dystonia of the feet. One well-known indication, for which however sufficient data are still lacking, involves treating tremor with BoNT. As to autonomic symptoms: Focal hyperhidrosis and detrusor hyperactivity can be mentioned, in this last case BoNT has already been approved. A number of further but rare indications such as freezing-of-gait, dyskinesia, and dysphagia will be discussed and evaluated.

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