Consensus for the measurement of the camptocormia angle in the standing patient

doi:10.1016/j.parkreldis.2018.06.013

Parkinsonism & Related Disorders

Volume 52, July 2018, Pages 1-5

https://doi.org/10.1016/j.parkreldis.2018.06.013 Get rights and content

Highlights

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There is no agreement on how to measure the camptocormia angle. Therefore studies on camptocormia are not comparable.
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In this paper four different methods of angle assessment were empirically evaluated regarding reliability and face validity.
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A consensus could be reached to measure a total camptocormia angle and an upper camptocormia angle.
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Apps are available to measure these angles (http://www.neurologie.uni-kiel.de/de/axial-posturale-stoerungen/camptoapp).

Abstract

Introduction

Camptocormia is characterized by a pathological forward flexion of the trunk, which is reversible when lying and worsened by standing and walking. So far there is no consensus on how to measure the angle of flexion, and studies therefore give differing results. Harmonization is needed for both research and clinical practice. Orthopedic measures are not useful for this purpose.

Methods

Two expert raters independently analyzed the photographs of 39 Parkinson patients with camptocormia while standing. They used four different methods to determine the camptocormia angle. The results were compared statistically. An international Consensus Group reviewed the results and drafted recommendations.

Results

The four methods yielded camptocormia angles that differed by up to 50% in the same patient. Inter-rater reliability and test-retest reliability also differed, but were satisfactory to excellent.

Conclusion

This Consensus Group concluded that two of the methods qualified as reliable measures of the trunk angles in standing patients based on their clinimetric properties. They propose that the ‘total camptocomia angle’ be the angle between the line from the lateral malleolus to the L5 spinous process and the line between the L5 spinous process and the spinous process of C7. They also propose that the ‘upper camptocormia angle’ be the angle of the lines between the vertebral fulcrum to the spinous processes of L5 and C7, respectively. An app is provided on the web for these measurements (http://www.neurologie.uni-kiel.de/de/axial-posturale-stoerungen/camptoapp).

Introduction

Camptocormia is an involuntary, non-fixed, pathological forward flexion of the trunk frequently associated with Parkinson's disease (PD) [1,2]. The condition is reversible when the patient is lying. This symptom is often more bothersome for the patient than the cardinal symptoms of PD itself. So far there is no established treatment for camptocormia [3]. Discontinuation of dopamine agonists [4] and chemodenervation with botulinum toxin or lidocaine have been recommended [[5], [6], [7], [8]]. Case series have shown that deep brain stimulation in the subthalamic nucleus or the globus pallidus internus may improve camptocormia at least during the first years after disease onset [9,10].

Cohort studies have found a prevalence of camptocormia of 5–19% [11]. There are many reasons for this broad range, among which are (1) cohort differences, as the condition is mainly observed in late disease stages, (2) differences in the a priori threshold angle (between 15° and 45°) used to define the diagnosis of camptocormia, and (3) differences in the methods themselves used to measure the camptocormia angle.

In order for epidemiologic and interventional studies of camptocormia to give meaningful results, there must be a general consensus on the method for determining the patient's flexion angle and on the diagnostic threshold angle. There are currently three commonly used methods for measuring the flexion angle [1,8,11]. Methods proposed for orthopedic surgery are not a valid alternative because they mainly address spinal mobility and not posture, and if posture is addressed they rely mainly on radiological findings [12]. This study assesses the advantages and disadvantages of each method as well as those of a new method and concludes with a recommendation.

Section snippets

Patients and methods

Thirty-nine patients with camptocormia and PD according to the UK Brain Bank PD criteria were recruited from the movement disorders outpatient clinic at the Department of Neurology, Kiel University. The diagnosis of camptocormia was based on patient complaints of an involuntary forward flexion of the trunk and confirmation of this condition during a full clinical assessment by a movement disorder neurologist. No a priori definitions of the camptocormia angle were used to make the diagnosis.

Results

The clinical and demographic data of the cohort are shown in Supplementary Table S1.

The different methods were applied to all patients and the results were used in the analysis. The fulcrum method yielded the largest angles of camptocormia (mean 56.7°) followed by the malleolus (41.6°) and the perpendicular method (33.1°). The upper camptocormia angle measurement gave a mean angle of 45.4°. The differences were statistically significant (p < 0.001) (Fig. 2, Supplementary Table S2).

Inter-rater

Discussion

Forward flexion in camptocormia comprises two components: the hip-angle, which represents the lower camptocormia angle and the angle produced by the angulation of the different vertebrae along the spine, which is collectively referred to as upper camptocormia. Together they give the total camptocormia angle, which is the most important measure for the patient. These angles can be determined precisely only by radiography, and the available tools for orthopedic surgery indeed mostly use

Consensus recommendation

We recommend the malleolus method as the standard for future measurements of the total camptocormia angle and recommend measuring the upper camptocormia angle separately, particularly in the context of interventional trials (Fig. 3). We propose to use the term ‘total camptocormia angle’. The ‘upper camptocormia angle’ as defined here is based on earlier work [8,15] and can serve to identify the specific contribution of the vertebral column to total camptocormia. Photographs should be taken

Author roles

Contributions to the current study (A: study concept and design; B: acquisition of data; C: analysis and interpretation; D: critical revision of the manuscript for important intellectual content).

NM, RW, OG, GD: A, B, C, D
All other authors: A, C, D.

COI

NGM has received lecture fees from Merz Pharmaceuticals and Bayer Pharmaceuticals and a travel grant from Eisai. He is a government employee in the Department of Neurology, University of Kiel, Germany.

RW, OG and RD have nothing to declare.

AJE has received grant support from the NIH, Great Lakes Neurotechnologies and the Michael J. Fox Foundation; personal compensation as a consultant/scientific advisory board member for Abbvie, TEVA, Impax, Acadia, Acorda, Cynapsus/Sunovion, Lundbeck, and

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Short communicationConsensus for the measurement of the camptocormia angle in the standing patient

Highlights

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Consensus recommendation

Author roles

COI

Postural deformities in Parkinson's disease

Lancet Neurol.

Camptocormia: pathogenesis, classification, and response to therapy

Neurology

Pathophysiological concepts and treatment of camptocormia

J. Parkinson's Dis.

Drug-induced camptocormia: a lesson regarding vascular Parkinsonism

Intern. Med.

Goal attainment after treatment of parkinsonian camptocormia with botulinum toxin

Mov. Disord.

Improvement in dystonic camptocormia following botulinum toxin injection to the external oblique muscle

Park. Relat. Disord.

An update on new and unique uses of botulinum toxin in movement disorders

Toxicon

Long-term effect of repeated lidocaine injections into the external oblique for upper camptocormia in Parkinson's disease

Park. Relat. Disord.

Short communication
Consensus for the measurement of the camptocormia angle in the standing patient