Objective: We elucidated whether and how asymmetric basal ganglia dysfunction is associated with the generation of Pisa syndrome (PS) in Parkinson’s disease (PD). To assess the influence of laterality of basal ganglia functioning on PS, we also identified the characteristics discriminating between PD patients with PS tilting to the less affected hemibody side of motor symptom and those who tilting to the more affected side.

Background: Pisa syndrome (PS) is defined as a lateral tilt of the trunk that can be diminished by passive movement or in supine position. It is a devastating postural deformity in patients with Parkinson’s disease (PD), leading to dyspnea, pain, and postural imbalance. Many factors, including asymmetric basal ganglia dysfunction, sensorimotor integration failure, musculoskeletal problems, and dystonia contribute to the pathogenesis of PS, making its treatment more complicated. Asymmetric functioning of basal ganglia has long been considered as a primary pathomechanism of PS. However, several studies have reported that neither laterality nor asymmetry of motor symptoms was associated with PS. A recent autopsy study also did not confirm the asymmetric involvement of PD pathology in a PD patient with PS. Nevertheless, due to a lack of the comprehensive and systematic approach, the pathogenic role of asymmetric functioning of basal ganglia in generation of PS remains unclear.

Methods: Fifty-four PD patients with PS and 36 without PS were tested for the asymmetry and dominant side of motor symptom. We also evaluated potentially relevant factors to PS by assessing the deviation of subjective visual vertical, electromyographic patterns of paraspinal muscles, bithermal caloric tests, and history of back pain. Multivariable logistic regression analysis was conducted to examine the effects of asymmetry of motor symptom and possible confounders.

Results: Asymmetry of motor symptom was an independent risk factor for PS tilting to the less affected side (OR 3.665; 95% CI 1.265 to 10.621; p=0.017), even though it did not differ between PD patient with PS and those without. In addition, unilateral canal paresis in the same side of PS (OR 19.671; 95% CI 1.136 to 340.539; p=0.041) and rightward deviation of subjective visual vertical (OR 0.005; 95% CI 0.000 to 0.343; p=0.014) were associated with PS tilting to the more affected side.

Conclusions: Asymmetric basal ganglia dysfunction contributes to PS by determining the direction of PS, toward the less affected side of motor symptom. Other factors, including unilateral vestibular hypofunction and verticality misperception, may generate PS tilting to the more affected side in PD patients with PS.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/does-the-basal-ganglia-dysfunction-affect-pisa-syndrome-in-parkinsons-disease/