Axial Posture in Parkinson's: What the Research Shows, and What It Doesn't

In Brief

More than one in five people with Parkinson's develop a severe change in trunk or neck posture — bending forward (camptocormia), leaning sideways (Pisa syndrome), or dropping the head (antecollis). This 2023 Viewpoint from the International Parkinson and Movement Disorder Society Task Force is a critical assessment of what the research establishes. Its conclusion is candid: there is still no agreed way to manage or prevent these postures, and the treatments studied so far were tested in small single-centre studies that failed to show consistent, lasting improvement.

What the Paper Shows

• Severe axial postural abnormalities affect over 20% of people with Parkinson's; mild forms are near-universal, and they raise the risk of falls, pain, and reduced quality of life.
• In multiple system atrophy they are more frequent, and appear earlier, than in Parkinson's disease.
• Dystonia is the most-supported mechanism, backed by drug-induced cases, occasional relief from sensory tricks, and improvement with botulinum toxin.
• Myopathy contributes, but the evidence marks it as a secondary consequence of chronically maintained abnormal posture rather than a cause.
• Postural improvement after deep brain stimulation of the subthalamic nuclei implicates basal-ganglia dysfunction.

What the Paper Does Not Show

This is the section most summaries omit, and the one that matters most — the authors are direct about the limits of the evidence.

• No definitive cause is established, and no way to predict who will develop these postures.
• Rigidity has never been specifically and systematically studied in this context.
• EMG findings conflict, particularly on which side of the body shows muscle overactivity in Pisa syndrome.
• Whether cognitive and proprioceptive deficits cause these postures, result from them, or merely coincide with more advanced disease remains unresolved — the authors leave all three possibilities open.
• No treatment is proven to prevent or reverse them.

Clinical Implications

The paper's recommendations are explicitly expert-opinion-based, and it says so. Clinicians are advised to measure trunk and neck flexion objectively (the Task Force recommends photographing the patient from at least three metres away and using the free NeuroPostureApp), to check for mild forms at every visit before they progress, and to inform and educate patients and caregivers early. Medication review, botulinum toxin in carefully selected cases, physiotherapy, and — where a patient is already a candidate — deep brain stimulation are options, each weighed individually.

Questions That Remain Unanswered

• What actually causes each posture, and do camptocormia, Pisa syndrome, and antecollis differ in their risk factors and mechanisms?
• Can early, consensus-based measurement predict who is at risk?
• Does any intervention — or any prevention programme — change the trajectory?

Think & Move Well Perspective

Our commentary, not a finding of the paper.

Two of this paper's calls speak directly to what we do: inform and educate patients and caregivers, and investigate prevention. Both are named by the Task Force as unmet needs.

We are precise about the limit: this paper does not evaluate any training method, including ours. It contains no intervention data. Its discussion of proprioception and cognition sits in territory that motor learning addresses — but the authors explicitly leave open whether those deficits cause these postures or merely accompany them, and so do we. We do not claim our approach treats, prevents, or reverses axial postural abnormalities.

Key Takeaways

1. Axial postural changes are common in Parkinson's and genuinely disabling — not a failure of effort.
2. The science is unsettled: no agreed cause, no reliable predictor, and no proven treatment.
3. Posture here is not only a muscle problem — perception and cognition are implicated, though unproven.
4. Early detection is the one clearly actionable step, and patients can raise it with their clinician.

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Educational information, not medical advice. Discuss any change in posture with your neurologist before decisions about care, exercise, or medication. Never adjust Parkinson's medication without medical supervision — the paper itself warns that withdrawal can worsen the underlying condition.

Reference: Geroin C, Artusi CA, Nonnekes J, et al. Axial Postural Abnormalities in Parkinsonism: Gaps in Predictors, Pathophysiology, and Management. Mov Disord. 2023;38(5):732–739. doi:10.1002/mds.29377

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