Posture and Parkinson disease
This month the PWR! Virtual Experience theme is Posture and it is a great excuse to PWR! Up with some antigravity core strengthening! As a newborn, you already did the hard work of developing your postural muscles as you struggled to hold your head up in “tummy time” or to scoot, roll, sit, or stand to get to favorite toys! Unfortunately, our lifestyle (e.g., injuries, bad habits, diet, stress) can take a toll on our musculoskeletal health. And, for PWP, worsening of posture is one of those “axial” symptoms that doesn’t respond robustly or at all to medications or deep brain stimulation.
To understand more about how PD-related posture changes affect YOU and what rehabilitation and exercise interventions may help - read Part 1.
To find a detailed explanation of posture and a summary of the pathophysiological mechanisms that contribute to postural changes in normal aging and PD please read Part 2.
What do we mean by Posture? Part 2
Posture refers to the alignment of the body when you are weight-bearing (i.e., standing, sitting, or lying down) or when you are moving (i.e., walking, sit to stand, getting on/off the floor). Good posture places the least strain on muscles and ligaments and maintains the natural curves of the spine (i.e., cervical, thoracic, lumbar) (Figure 1). The spinal curves form an S-shape and not only keep our head, shoulders and hips aligned with each other, but they also act as a shock absorber, allow for spinal mobility, and help maintain balance.
These curves are maintained by two muscle groups, the flexors and extensors. The flexor muscles are on the front of the body and include chest, diaphragm, and abdominal muscles. These muscles enable us to bend, push, rock, reach, or step forward and are important in controlling the lumbar curve of the spine. The extensor muscles are on the back of the body and include spinal, pelvic floor, and hip muscles. These muscles allow us to stand and walk upright, get up off the floor, stand up from a chair, and lift, hold, or carry objects. Working together these muscle groups work together (i.e., core muscles) to stabilize your spine and keep it in optimal alignment.
Posture changes occur in normal aging and in Parkinson disease (PD) but the underlying mechanisms may differ (Table 1). The prevalence of posture changes in early PD is 73% and is significantly higher than the 20%-40% prevalence reported in the healthy older population. In addition, the posture changes related to PD progress with disease severity and often co-exist with posture changes related to normal aging.
Table 1 . Posture changes and pathological mechanisms.
Changes that occur in posture with normal aging
• Routinely poor posture
• Loss of flexibility, spinal mobility, stiffness, pain
• Age-related stooped posture - anterior concavity of thoracic spine (kyphosis)
• Worsens with age
Pathological Mechanisms (related to normal aging)
• Loss of bone density
- Osteoporosis
- Fractures
• Dehydration, hardening and shrinkage of the intervertebral discs (gelatin-like cartilage)
- Degenerative osteoarthritis
- Vertebral compression fractures
• Extensor muscle weakness due to muscle mass shrinkage and replacement by fat or fibrous tissues
• Pain
• Depression
Additional changes that occur in posture in PWP
• PD-related stooped posture involved flexion of the trunk, hips, and knees, flattening of the low back curve, rounded shoulders and dropped head/eyes down
• Worsens with age and disease severity
• Anterior flexion may be a compensation for reduced balance, to protect against backward displacement
Pathological Mechanisms (related to Parkinson disease)
• Rigidity (biased muscle activation favoring flexors)
• Muscle dystonia
• Body scheme defects due to centrally impaired proprioception
• Specific loss of spinal proprioception
• Defective sensory integration processing (visual, vestibular, proprioception)
• Impaired perception of verticality perception
Aging and Parkinsons
In aging, posture changes are usually due to an exaggerated thoracic curve (kyphosis)(Figure 2). The pathological processes that occur with aging and that contribute to loss of spinal mobility, stiffness, pain and postural deformities are summarized in Table 1.
In PWP, posture changes begin with anterior flexion of the trunk, hip and knee flexion and hip adduction (narrowing the base of support. This flexed posture results in an exaggerated thoracic curve, rounded shoulders such that the arms are in front of the body and flattening of the lumbar curve (Figure 2).
In a subset of PWP with posture changes (~30%) become more severe, leading too structural deformities and significant disability. These postural deformities include camptocormia, antecollis, Pisa syndrome, and scoliosis. These severe deformities occur in different planes of motion (anterior, lateral) and may be associated with PD or different atypical parkinsonisms. The underlying pathophysiology of these deformities is largely unknown.
Camptocomia is the most common postural abnormality in this group of individuals and involves severe anterior trunk flexion which resolves when lying on back. Antecollis involves anterior flexion of the neck, or “dropped head” and does not resolve when lying down on the back. Pisa syndrome involves lateral flexion of the trunk that does resolve upon lying down on the back. Scoliosis involves both lateral flexion of the spine and rotation of the vertebrae.
Ready to get started? Not sure what to do?
Schedule an appointment with one of our PWR!Gym Therapists to assess your balance control and provide you with a personalized plan.
Working 1:1 with a physical therapist is the most efficient and effective way to “retrain” balance, group exercise is the most effective way to “sustain” the gains from therapy! Guess what? At the PWR!Gym, we can give you access to both – intensive bouts of PD-specialized rehabilitation and group exercise training for life.
Come join us at the PWR! Virtual Experience and live YOUR “Life in Balance.”
Our goal is to make sure you’re always empowered and informed.
We offer handouts, downloads, research updates, Wellness Series talks, retreats with knowledgeable speakers, in-person and virtual wellness consultations, and in-person physical therapy visits. We are here for our PWR! Members every step of the way.
We’re excited to have you join us!
References
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2. Ashour R, Jankovic J. Joint and skeletal deformities in Parkinson’s disease, multiple system atrophy, and progressive supranuclear palsy. Mov Disord 2006;21:1856-63
3. Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related hyperkyphotic posture: A systematic review. Arch Phys Med Rehabil. 2014;95(1):129-140. doi:10.1016/j.apmr.2013.06.022
4. Capecci M, Serpicelli C, Fiorentini L, et al. Postural rehabilitation and kinesio taping for axial postural disorders in Parkinson’s disease. Arch Phys Med Rehabil. 2014;95(6):1067-1075. doi:10.1016/j.apmr.2014.01.020
5. Debû B, De Oliveira Godeiro C, Lino JC, Moro E. Managing Gait, Balance, and Posture in Parkinson’s Disease. Curr Neurol Neurosci reports. 2018;18(23). doi:10.1007/s11910-018-0828-4
6. Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. Lancet Neurol. 2011;10(6):538-549. doi:10.1016/S1474-4422(11)70067-9
7. Forsyth AL, Paul SS, Allen NE, Sherrington C, Fung VSC, Canning CG. Flexed truncal posture in Parkinson disease: Measurement reliability and relationship with physical and cognitive impairments, mobility, and balance. J Neurol Phys Ther. 2017;41(2):107-113. doi:10.1097/NPT.0000000000000171
8. Gandolfi M, Tinazzi M, Magrinelli F, et al. Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson’s disease: A single-blinded, randomized controlled trial. Parkinsonism Relat Disord. 2019;64. doi:10.1016/j.parkreldis.2019.05.006
9. Grasso R, Zago M, Lacquaniti F. Interactions between posture and locomotion: Motor patterns in humans walking with bent posture versus erect posture. J Neurophysiol. 2000;83(1):288-300. doi:10.1152/jn.2000.83.1.288
10. Jankovic J. Camptocormia, head drop and other bent spine syndromes: heterogeneous etiology and pathogenesis of Parkinsonian deformities. Mov Disord. 2010;25(5):527-528. doi:10.1002/mds.23139
11. Lee KH, Kim JM, Kim HS. Back extensor strengthening exercise and backpack wearing treatment for camptocormia in Parkinson’s disease: A retrospective pilot study. Ann Rehabil Med. 2017;41(4):677-685. doi:10.5535/arm.2017.41.4.677
12. Margraf NG, Wrede A, Rohr A, et al. Camptocormia in idiopathic Parkinson’s disease: A focal myopathy of the paravertebral muscles. Mov Disord. 2010;25(5):542-551. doi:10.1002/mds.22780
13. Mori L, Putzolu M, Bonassi G, et al. Haptic perception of verticality correlates with postural and balance deficits in patients with Parkinson’s disease. Park Relat Disord. 2019;66:45-50. doi:10.1016/J.PARKRELDIS.2019.06.026
14. Muthukrishnan N, Abbas JJ, Shill HA, Krishnamurthi N, Edu JA. Cueing Paradigms to Improve Gait and Posture in Parkinson’s Disease: A Narrative Review. Sensors. 2019;19:5468. doi:10.3390/s19245468
15. Okada Y. Galvanic Vestibular Stimulation for Camptocormia in Parkinson’s Disease: A Case Report. J Nov Physiother. 2012;01(S1):1-4. doi:10.4172/2165-7025.S1-001
16. Okada Y. Rehabilitation for Postural Deformities in Parkinson’s Disease: An Update and Novel Findings. J Nov Physiother. 2014;04(05). doi:10.4172/2165-7025.1000233
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18. Ye BK, Kim H-S, Kim YW. Correction of Camptocormia Using a Cruciform Anterior Spinal Hyperextension Brace and Back Extensor Strengthening Exercise in a Patient With Parkinson Disease. Ann Rehabil Med. 2015;39(1):128. doi:10.5535/arm.2015.39.1.128
Dr. Becky Farley About the Author
If you ask her, Dr. Becky Farley will tell you that working with her first client with Parkinson’s almost 20 years ago changed her life and her career, and since then she hasn't stopped changing lives of those living with Parkinson's, in Arizona and the rest of the world. In 2010, she established the PWR!Gym in Tucson and has been offering people with Parkinson disease the PD-specific physical therapy, group exercise, and social engagement they need to get better and stay better. Globally, Dr. Farley supports PWR!’s mission of making cutting-edge PD-specific "exercise as medicine” available to the 10 million people living with PD worldwide, by training healthcare and fitness professionals in the PWR!Moves and the PWR!4Life model (and she’s trained over 6000 professionals since she started in 2010!).
When she’s home in Arizona, you’ll find Becky working on PD-specific exercise at the PWR!Gym as well as leading our annual exercise intensive PWR! Retreats. When she’s on the road, she’s either teaching our PWR!Moves workshops or giving talks at conferences, community organizations, and healthcare networks across the US and world.
When she isn’t working, you can find her working out, walking the dog, and gardening. To learn even more about Dr. Farley, visit our team page.
You can find Dr. Farley at: