Abstract
We elucidated whether verticality misperception is associated with the generation of Pisa syndrome (PS) in patients with Parkinson’s disease (PD). To examine the heterogenous influence of verticality perception, we also identified the characteristics distinguishing between PD patients with PS who tilted toward the deviation of perceived verticality and those who did not. Subjective visual vertical (SVV) testing was performed in 54 PD patients with PS and 36 without PS to measure verticality perception. Other potential risk factors for PS were evaluated by assessing the asymmetry of motor symptoms, EMG activities of paraspinal muscles, bithermal caloric tests, back pain history, and Berg Balance Scale. Abnormal SVV (odds ratio (OR) 18.40, p = 0.006), postural imbalance (OR 0.71, p = 0.046), and unilateral EMG hyperactivity of paraspinal muscles (OR 39.62, p = 0.027) were independent contributors to PS. In subgroup analysis, EMG hyperactivity of paraspinal muscles contralateral to the leaning side and postural imbalance were associated with PD patients with PS who tilted toward the SVV deviation, whereas back pain was more frequent in those who did not. Verticality misperception is a potent risk factor for PS in PD and contributes differentially to PS depending on the congruence between its direction and PS direction, indicating distinct pathogenic roles.
Highlights
Parkinson’s disease (PD) patients with Pisa syndrome (PS) show abnormal perception of verticality in the roll plane[7,8]
Unilateral EMG hyperactivity of paraspinal muscles was only observed in PD with PS (PD-PS) patients (Table 1), which was uniformly contralateral to the leaning side (Fig. 3)
There were no differences in age, gender, disease duration or severity, motor subtype, dominant side of motor symptoms, levodopa equivalent daily dose (LEDD), treatment regimens, body mass index (BMI), or Mini-Mental State Examination (MMSE) between groups
Summary
PD patients with PS show abnormal perception of verticality in the roll plane[7,8]. To maintain an upright posture, sensory information from visual, vestibular, and somatosensory systems is centrally integrated to provide information to align the internal representation of the body axis with the earth-vertical[9] Damage to this integrative procedure may alter verticality perception, leading to postural misalignment. Impaired verticality perception, measured with subjective visual vertical (SVV) tests, is associated with lateral body tilts in several neurological conditions, including pusher syndrome and lateral medullary infarctions[10,11]. In these patients, body tilts are observed in the same direction of pathological perceived verticality, suggesting a primary pathogenic role of verticality misperception[10,11].
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