August: All about posture

Learning a little more about how to stay tall and centered

August 15, 2024

Welcome to our first official monthly newsletter! We will strive each month to utilize the latest research to bring you simplified and up to date information on new topics relevant to people with Parkinson’s. We will work on implementing how to work on each of these issues within our Ignite exercise classes as well.

August’s Theme: Posture

Let’s talk about posture and Parkinson’s. We are all familiar with this word, but what does it really refer to…especially how does it relate to Parkinson’s?

There is still some debate as to why postural changes happen for People with Parkinson’s, but generally the cause is believed to be multi-factorial. These contributing factors include increased muscle tone around the trunk (rigidity), involuntary muscle spasms in the trunk or neck (dystonia), central changes in the brain of body awareness/movement awareness (proprioceptive and vestibular processing), and rarely a muscle disorder causing weakness (myopathy). As the above symptoms cause changes in posture then you can get the secondary effects of actual structural changes of the spine and increase in pain.

There are four main types of true postural deformities that some people with Parkinson’s can develop:

  1. Camptocormia: excessive forwards bending of the trunk (flexion) that appears in standing, sitting or walking but disappears upon laying down. Meaning you are not stuck in a bent posture. Studies show this is most common with people with trunk spams/muscles contractures that only happen when active (action axial dystonia).

  2. Pisa Syndrome: A sideways or lateral bending of the trunk in sitting, standing, or walking that disappears when laying down.

  3. Scoliosis: a lateral curvature of the spine with concurrent twisting (rotation) creating an “S” curve. A very common spinal condition, but more common for people with PD compared to age related norms

  4. Anterocollis: Significant forwards bending of the neck without concurrent excessive forwards bending of the rest of the spine. There is evidence showing possible risk of onset with use of Dopamine agonist medications.

    * I want to stress that the majority of people who have Parkinson’s disease do not get these more severe postural conditions, but almost all people will feel some level of postural changes from their disorder.

As you can see, posture changes in Parkinson’s is complex which of course means figuring out how to prevent these changes and even improve them can be even more challenging. Although strengthening of the back and neck muscles will be of some benefit, I am sure many of you have felt like it was only scratching the surface of the problem.

Lets take a dive together into what the research and experts recommend to stay tall and centered:

When in doubt, it is always safe to read through a new systematic review article. Luckily we have one that came out this year on Posture and PD:

This pretty much sums up all the treatment options available for postural abnormalities that occur with Parkinson’s. Here it is in a nutshell:

  1. Medication: In theory oral medications for PD, like levodopa, should help reduce muscle tone which should help improve postural abnormalities, but unfortunately the results are highly variable. That being said, if you are noting a sudden change in your posture in any of the above subtypes then one of the first steps you should do is check in with your neurologist on medication adjustments

  2. Botox and lidocaine injections: This can be very helpful for more focal dystonia (muscle contractions/spasms in a single muscle, ie your foot), but has had limited effects on postural abnormalities. Part of this is due to the limited evidence available using these on the muscles of the trunk ( abdominal and back muscles). These muscles are so important for our balance and keeping our self upright that is may be too risky to inject them with something that can weaken them as a side effect.

  3. Deep brain stimulation: Finally something that seems to be more consistently helpful! There is good evidence supporting the benefit of DBS on posture, at least retrospectively. If you are considering getting DBS and are feeling significant changes in your posture that have not improved with other treatment methods this may be another reason supporting undergoing the implant.

  4. Spine Surgery: Results are very mixed here. Although there is some improvement in pain and temporary improvement in posture with surgery, the rate of complications and revisions for PWP is very high. So proceed with caution if you are considering a surgical option.

  5. Rehabilitation and Exercise!! (of course our very favorite): Many of these studies are small, but they are showing very positive results. The over arching pattern in the research here shows that active movement is much more effective than passive ones, high intensity matters (of course), and the earlier you start the better.

    This makes sense with all we know about the benefits of exercise in general for PWP. The most promising approaches focus on “improving sensorimotor integration processes and enhancing feedforward and cognitive control of postural control (dual tasking).”

    But what does this actually mean?! Basically sensorimotor integration is our brains taking all the sensory input (from our eyes, inner eyes, and receptors in all our joints) and processing this information to give us awareness of where we are in space and how we are moving. Enhancing feed forwards and cognitive control of posture is talking about having more conscious awareness of your position, movements, and reactions until it becomes more automatic again. These studies have shown that doing these focused trunk specific exercise program with active stretching, balance, and strengthening exercises, especially with concurrent feedback or altered sensory input, can lead to reversal of postural changes. This is taking it one step further than your basic back strengthening or stretching program!

    So simply, we need to add more awareness to what we are feeling and how we are posturing to make changes. This is something we can easily do every day, especially while you are exercising. There is also positive research showing the benefits of water exercise to change postural abnormalities as it changes a person’s sensory experience and awareness. Lastly, it is common for PWP who have postural abnormalities to have pain as well and physical therapy focused on improving posture has been shown to improve pain.

    Fig. 3. An algorithmic approach to the management of PA in PD.

    Although this article sums it all up, I have also added a few other article links below that dive deeper into the exercise and rehabilitative options to improve posture, including the techniques they use. These are things that we use with our patients in physical therapy all the time to try to improve their postural control. We also integrate these strategies into our exercise classes at Ignite. Think about anything that changes your awareness of your body while you are actively moving: adding weight, vibration, visual targets. Then just repeat this 10,000 times and it will become more automatic. And unfortunately I am not kidding about that number….the more the better! The key is to start thinking about these changes now and engage in conscious exercise and movement to prevent postural changes before they happen.

So in summary, you can see there is more than one viable option to prevent progression of postural changes from PD. The combination of proper medical management with appropriate exercise and movement awareness will lead to best results. And as with most symptoms with PD, these postural changes are reversible, especially if managed early. So start moving and bringing awareness to your posture ASAP. If you feel overwhelmed by this thought or cannot figure out to start improving your movement/postural awareness please reach out to us or your physical therapist to give you the jump start you need.

As always, please feel free to reach out to us with any additional questions or comments you have about this topic. If this information sounds helpful to someone else you know, please feel free to share the newsletter.

The more you know, the taller you will stand,

Laura