Diagnostic criteria for camptocormia in Parkinson's disease: A consensus-based proposal

Abstract

Introduction: Camptocormia is defined as an involuntary, marked flexion of the thoracolumbar spine appearing during standing or walking and resolving in the supine position or when leaning against a wall. However, there is no established agreement on the minimum degree of forward flexion needed to diagnose camptocormia. Likewise, the current definition does not categorize camptocormia on the basis of the bending fulcrum.

Methods: We performed a survey among movement disorders experts to identify camptocormia using images of patients with variable degrees and types of forward trunk flexion by fulcrum (upper and lower fulcra). We tested the subsequently generated diagnostic criteria in a sample of 131 consecutive patients referred for evaluation of postural abnormalities.

Results: Experts reached full consensus on lower camptocormia (L1-Sacrum, hip flexion) with a bending angle ≥30° and upper camptocormia (C7 to T12-L1) with a bending angle ≥45°. This definition detected camptocormia in 9/131 consecutive PD patients (2 upper/7 lower) but excluded camptocormia in 71 patients considered to have camptocormia by the referring neurologist.

Conclusions: Camptocormia can be defined as "an involuntary flexion of the spine appearing during standing or walking and resolving in the supine position of at least 30° at the lumbar fulcrum (L1-Sacrum, hip flexion, i.e. lower camptocormia) and/or at least 45° at the thoracic fulcrum (C7 to T12-L1, i.e. upper camptocormia)". Strict criteria for camptocormia are met by 7% of patients with abnormal posture. The ascertainment of upper and lower camptocormia subtypes could improve the validity of epidemiological studies and assist future therapeutic trials.

Keywords: Back pain; Bent spine syndrome; Camptocormia; Postural abnormalities; Stooped posture.

Fig. 1.

Two example of upper (A) and lower camptocormia (B) according to the definitions reached by full consensus by the panel of experts. Upper and lower camptocormia was measured according to the clinical method used by Furusawa et al. using C7, fulcrum of trunk deviation and the vertical line for the upper camptocormia and C7, sacrum and the vertical line for lower camptocormia [19]. This goniometric modality to quantify postural deformities was chosen due to the relatively easy way to quantify trunk angles during a routine visit and its ability to distinguish two spinal regions (thoracic and lumbar/sacral) which contribute differently to spinal motion [24]. The lumbar/sacral region was considered as a single functional unit because a strict relationship between the pelvic tilt and lumbar lordosis exists during standing posture. Indeed, increasing of the degrees of anterior pelvic tilt increases the angle of lumbar lordosis, and vice versa [25]. Panel C shows the angle distribution of patients with FTB and camptocormia.