Objective: Our study aimed at evaluating the clinical and electromyographical effects of botulinum toxin (BoNT) injections in patients with Pisa syndrome (PS) in Parkinson’s disease (PD) after 1 and 3 months.

Background: PS consists of a lateral flexion on the spine, a common dystonic posture in patients with PD associated to muscle hyperactivity ipsi- or contralateral to the bending side [1]. BoNT acts by blocking the presynaptic release of acetylcholine at the neuromuscular junction level [2].

Method: This pilot study involved 16 patients with PD and PS, recruited from the Movement Disorders Unit of Trieste (Italy) between March 2021 and March 2023. Each patient was evaluated at baseline, 1 month and 3 months after BoNT injection, which was always ipsilateral to the bending site regardless of EMG activation. We recorded demographic, PD- and PS-related clinical variables, including measure of self-perceived health (PDQ-8 and PGIC scales), and back pain evaluation (VAS scale). Muscular hypo- and hyperactivity patterns were assessed by superficial EMG recording. Lateral bending angle of the spine was calculated on planar view photographs as the angle between the vertical axis and a line connecting the fulcrum of the bent spine with C7 spinous process.

Results: Sixteen outpatients (44%F; 73±6yo; disease duration 6±3 years) showed an initial reduction in bending degrees followed by a reversion (6.5±3, 5±1.5, 6.7±6 degrees at baseline, 1 and 3 months respectively; difference between baseline and 1 months p .1232), a substantial stability in PDQ-8 scores (4±3.2, 3.3±2.8, 4±3.9), and a reduction in back pain (VAS 3.9±3.2, 2.1±2.3, 2.9±3.4; difference between baseline and 1 month p .0044, between baseline and 3 months p .4470). After 1 and 3 months, 91 and 100% of the patients respectively reported a global improvement (PGIC scores ≥3). Qualitative EMG signal analysis showed an almost uniform improvement in global paraspinal muscle activation.

Conclusion: Our study shows an efficacy in bending angle reduction after 1 month from the treatment and a reversion after 3 months (as expected from BoNT pharmacodynamic), and a subjective clinical improvement extending beyond this time limit. These data may indicate that BonT injection ipsilateral to the bending side regardless of EMG activity may benefit PD patients with PS.

References: [1] Doherty KM, van de Warrenburg BP, Peralta MC, Silveira-Moriyama L, Azulay JP, Gershanik OS, Bloem BR. Postural deformities in Parkinson’s disease. Lancet Neurol. 2011 Jun;10(6):538-49. doi: 10.1016/S1474-4422(11)70067-9. Epub 2011 Apr 22. PMID: 21514890.
[2] Tassorelli C, De Icco R, Alfonsi E, Bartolo M, Serrao M, Avenali M, De Paoli I, Conte C, Pozzi NG, Bramanti P, Nappi G, Sandrini G. Botulinum toxin type A potentiates the effect of neuromotor rehabilitation of Pisa syndrome in Parkinson disease: a placebo controlled study. Parkinsonism Relat Disord. 2014 Nov;20(11):1140-4. doi: 10.1016/j.parkreldis.2014.07.015. Epub 2014 Aug 13. PMID: 25175601.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/pisa-syndrome-and-botulinum-toxin-injection-in-paraspinal-muscles-ipsilateral-to-the-bending-side-a-pilot-study/