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In sagittal plane Camptocormia Definition camptocormia is used to describe a distinctive and much more pronounced manifestation of this stooped

posture, with flexion originating in the thoracic or lumbar spine 1 From a biomechanical point of view, the spinal kyphosis causes a forward and downward shift of the centre of mass (COM) of the trunk in the sagittal plane. When the other segments do not change position, it will induce a forward and downward shift of the body COM with respect to the base of support To maintain body balance, a patient has to correct for this shift. Joints of the lower limbs can compensate for the sagittal displacement of the trunk COM. flexion of the hips, flexion of the knees and plantar flexion of the ankles may counterbalance the forward shift of the body COM relative to the base of support. Compensation by the ankles is very efficient, as it demands little plantar flexion of the ankle joints. However, it hardly influences the horizontal view. When the hips are used for compensation, a larger change in joint angle is needed to reach the same result concerning the COM displacement compared to compensation by the ankle joints. Nevertheless,extension of the hips is beneficial as it induces a posterior rotation of the pelvis and results in a large increase in trunk angle. The more the trunk is rotated posteriorly, the more the field of vision increases and the load on the lumbar spine could possibly decrease. The compensation may become insuffcient due to the progress of the disease, which could lead to a permanent displacement of the trunk COM.

2-Antecollis Definition
Antecollis in parkinsonian disorders refers to a forward flexion of the head and neck. 1 ----------------------------------------------------------------------

Coronal plane deformities Pisa syndrome and scoliosis Definitions


Pisa syndrome refers to a marked lateral fl exion of the trunk, which is typically mobile (it resolves, for example, on lying down). Scoliosis is defined as a lateral curve of the spine, usually combined with a rotation of the vertebrae.1

Problems
1-Posture abnormality 2-Specific muscle shortning 3-Specific muscle weakness

4-restricted lung capacity 5-Balance problems 2,3

Goals
Improve postural awareness Improve strength in weak muscles Improve rom in shortened muscles Improve trunk rigidity Improve respiratory function Improve postural stability 2,3

Interventions 2,3,4
1-Posture correction A .strength of weak muscles
a.back muscles

b. neck extensors c. hip extensors

d.knee extensors

e. dorsiflexors

f. shoulder retractos

g.shoulder elevators

b.stretch of shortened muscles


a.abdominal muscles

lateral trunk flexors,in case of scoliosis,pisa syndrome.1

b. neck flexors c.hip flexors

d.knee flexos (hamstrings)

e. ankle planter flexors f.pectoralis major and minor

c. Posture awareness training


cues such as using a mirror or wall to help correct a leaning posture in standing and sitting in front of mirror instruct patient to feel the neutral posture2,3

d. trunkal rigidity management ,2


-by using flexibility exercises

-and pnf techniques Rhythmic rotatition Trunk patterns p.n.f Flexion with rotation toward wright, left

-relaxtion techniqes

-using the swivel chair

-biofeedback if available

e. improve respiratory function


respiratory exercises: deep breathing exercises aerobic exercises: activities of upper limb with breathing(seated aerobics)

in sitting ,standing and walking ,2,3,1

3- p.n.f

f.postural stability training:


1-Training for postural strategies

,2,3

2-Upper limp activities during sitting ,standing ,walking

Others
1-Galvanic Vestibular Stimulation
Galvanic vestibular stimulation is the process of sending specific electric messages to a nerve in the ear that maintains balance. There are two main groups of receptors in the vestibular system: the three semi-circular canals, and the two otolith organs (the utricle and the saccule).

GVS markedly improved our patients camptocormia while standing. During the binaural monopolar GVS applied in this study, the cathode electrode of each pair was over the mastoid process and the anode electrode was over the trapezius muscle at the C7 level on the same side. The GVS applied to our patient with camptocormia may have activated both sides of the vestibular afferents to induce posterior body sway, even after the end of the GVS. The effects of GVS on the patients camptocormia were seen during the standing position with eyes closed, in particular. The results suggest that GVS might improve postural control by contributing to the processing of vestibular and somatosensory information. Although a quantitative assessment of the patients standing posture was not done, he reported in weekly telephone surveys that his standing and sitting in daily life were improved and the improvement continued up to 1 month

after the GVS. In light of other such reports by patients as Standing and sitting positions in daily life were improved after the GVS and that the improvement continued up to 1 month after the GVS, GVS may induce a plastic change in postural control. Our patients camptocormia worsened again 1.5 months after the GVS, although it was still better than before the GVS. The optimal intervention frequency for GVS should be examined in a future study. ,5 2- deep brain stimulation -Both sub thalamic nuclei,most common from exellent improvement to mild improvement -Glopus pallidus lesser extent,1 3-surgical correction if failed conservative treatment,1

References;
1- Postural deformities in Parkinsons disease by Karen M Doherty, Bart P van de Warrenburg, Maria Cecilia Peralta, Laura Silveira-Moriyama, Jean-Philippe Azulay, Oscar S Gersha nik, Bastiaan R Bloem.,2011 2345Neurological rehabilitation,darcy umphred ,5th ed,2005 Neurological intervntions,martin,Kessler,2nd ed ,2007 Therapeutic exercises,crolyn kisner, 5th ed,2007 Galvanic Vestibular Stimulation for Camptocormia in Parkinson s Disease: ,A Case Report, Okada et al., J Nov Physiother 2012, S1