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.


Introduction: Pisa syndrome (PS) is a tonic lateral flexion of trunk that represents a disabling complication of advanced Parkinson disease (PD). Conventional rehabilitation treatment (CT) ameliorates axial posture and trunk mobility in PD patients, but the improvement tends to wane in 4-6 months. Botulin toxin (BT) may reduce muscle hyperactivity, therefore improving CT effectiveness. We evaluated whether the injection of incabotulinum toxin type A (iBTA) into the hyperactive trunk muscles might improve the effectiveness of rehabilitation in a group of PD patients with PS.

Methods: Twenty-six PD patients were enrolled in a randomized placebo-controlled trial. Group A was treated with iBTA before undergoing CT (a 4-week intensive programme), while Group B received saline before the 4-week CT treatment. Patients were evaluated at baseline, at the end of the rehabilitative period, 3 and 6 months with kinematic analysis of movement, UPDRS, Functional Independence Measure and Visual Analog Scale for pain.

Results: At the end of the rehabilitation period, both groups improved significantly in terms of static postural alignment and of range of motion. Group A showed a significantly more marked reduction in pain score as compared with Group B and a more prolonged efficacy on several clinical and kinematic variables.

Conclusions: Our preliminary data suggest that BT may be considered an important addition to the rehabilitation programme for PD subjects with PS for improving axial posture and trunk mobility, as well as for a better control of pain.

Keywords: Botulinum toxin; Pain; Parkinson disease; Physical therapy; Pisa syndrome; Rehabilitation.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Video-Audio Media

MeSH terms

  • Aged
  • Aged, 80 and over
  • Biomechanical Phenomena
  • Botulinum Toxins, Type A / therapeutic use*
  • Double-Blind Method
  • Electromyography
  • Female
  • Humans
  • Male
  • Musculoskeletal Manipulations / methods*
  • Neuromuscular Agents / therapeutic use*
  • Parkinson Disease / complications*
  • Physical Therapy Modalities
  • Postural Balance / drug effects
  • Postural Balance / physiology
  • Range of Motion, Articular
  • Sensation Disorders* / drug therapy
  • Sensation Disorders* / etiology
  • Sensation Disorders* / rehabilitation
  • Treatment Outcome
  • Visual Analog Scale


  • Neuromuscular Agents
  • Botulinum Toxins, Type A