Pisa syndrome in Parkinson's disease: An integrated approach from pathophysiology to management

Pisa syndrome was first described in
1972 in patients treated with neuroleptics. Since 2003,
when it was first reported in patients with Parkinson’s
disease (PD), Pisa syndrome has progressively drawn
the attention of clinicians and researchers. Although
emerging evidence has partially clarified its prevalence
and pathophysiology, the current debate revolves
around diagnostic criteria and assessment and the
effectiveness of pharmacological, surgical, and rehabilitative
approaches. Contrary to initial thought, Pisa syndrome
is common among PD patients, with an
estimated prevalence of 8.8% according to a large survey.
Furthermore, it is associated with the following
specific patient features: more severe motor phenotype,
ongoing combined pharmacological treatment with
levodopa and dopamine agonists, gait disorders, and
such comorbidities as osteoporosis and arthrosis. The
present literature on treatment outcomes is scant, and
the uneven effectiveness of specific treatments has produced
conflicting results. This might be because of the
limited knowledge of Pisa syndrome pathophysiology
and its variable clinical presentation, which further complicates
designing randomized clinical trials on this condition.
However, because some forms of Pisa syndrome
are potentially reversible, there is growing consensus
on the importance of its early recognition and the
importance of pharmacological adjustment
and rehabilitation.