Layout 1 Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation | Maccarone & Masiero Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 Parkinsons’s disease (PD) is a chronic neurodegener- ative disorder characterized by progressive worsening of gait, posture and balance. Abnormal postures and spinal misalignment tend to reduce dexterity, disrupt gait, and interfere with daily life activities also increasing the sus- ceptibility to musculoskeletal pain or discomfort.1 This becomes particularly evident in more advanced stages of the disease where striking sagittal or coronal plane spinal deviations occur (e.g., anterocollis, scoliosis, camptocor- mia and Pisa syndrome) and are further worsened by the process of aging.2 Behind the origin of these clinical signs some authors suggest several peripheral (e.g., muscle ri- gidity, myopathy and soft tissue changes) and central causes (e.g., proprioceptive disintegration, dystonia and medication effects). However, the precise mechanism re- mains unclear.3 Spinal scoliosis is a common disorder in PD with a reported prevalence between 43% and 90%.4 Several experiments of artificially induced hemiparkinso- nism on animal models have been showing to induce sco- liosis, suggesting the possibility that this condition may have a neurologic background in some cases.1 It is largely known that spinal regions are not independent of one another, and that the alteration of one segment can have repercussion on the other segments.5 A study of Topalis and colleagues6 found a higher prevalence of neck pain in adults with idiopathic scoliosis. Shin et al.7 has shown that neck pain is associated with excessive cervical lordosis, upper thoracic kyphosis and altered shoulder and scapular kinematic in young women with forward head posture.7 In addition to spinal deformities, individuals with chronic pain were shown to display balance impairment in multi- ple studies.8,9 Despite the significant functional and quality of life impact of cervical pain and the vulnerability of these patients to Abstract Parkinson’s disease (PD) is defined by progressive worsening of gait, posture, and balance, as well as disability in daily life activities, and improvement in chronic musculoskeletal pain, particularly neck pain associated with worsening of balance. The study’s goal is to look into the relationship between scoliosis, balance, and cervical pain in Parkinson’s disease patients. Cross-sectional, pilot study. The study included 16 Parkinson’s patients. Neck cervical pain was measured using the pain visual analogue scale and the short form McGill pain questionnaire, while dynamic balance was assessed using static balance, Tinetti, Berg Balance, and the Short Physical Performance Battery scales (SPPB). Cobb angles are measured on a whole-spine standard X-ray to assess spinal scoliosis. An observational statistical analysis was performed with patients subdivided into two groups: non- scoliosis (NS) and true scoliosis (TS) based on whether they presented a Cobb’s angle below or ≥10°. Neck pain was reported by 37% (n=3) of participants in the NS group versus 50% (n=4) in the TS group. Neck pain was more prevalent in patients with a disease duration of less than 48 months (n=6; 75.0% vs n=1; 12.5%; p-value <0.05). Scoliosis, cervical pain, and postural imbalance are all significant but often overlooked Parkinson’s disease complaints. Key Words: Parkinson’s disease, scoliosis, postural imbalance, pain. Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 Is there any relationship between scoliosis, cervical pain and postural imbalance in Parkinson’s disease? A cross-sectional pilot study Gianpaolo Ronconi,1 Dario Mattia Gatto,2 Mariantonietta Ariani,2 Sefora Codazza,3 Fabio Ingravalle,4 Giorgio Ferriero,5,6 Daniele Coraci,7 Paola E. Ferrara3 1Catholic University of the Sacred Heart, Rome, Italy; 2Department of Neurosciences, Sense Organs and Thorax, Catholic University of the Sacred Heart, Rome, Italy; 3University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy; 4Hospital Health Management Area, Local Health Authority “Roma 6”, Albano Laziale, Italy; 5Unit of Physical and Rehabilitation Medicine, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Varese, Italy; 6Department of Biotechnology and Life Sciences, University of Insubria, Varese, Como, Italy; 7Department of Neuroscience, Section of Rehabilitation, University of Padova, Padua, Italy. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 27 - Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 develop spinal deformities and postural instability, so far, very little attention has been paid in the assessment of the relationship between these factors. Therefore, in this study, we aimed to investigate whether a correlation between sco- liosis, poor static and dynamic balance, and cervical pain exists in a group of patients affected by PD. To our knowl- edge no previous study has been published that investigated this kind of relationship. Materials and Methods For this pilot, cross-sectional study, 16 consecutive patients with idiopathic PD that presented a scoliotic posture were recruited from the Physical and Rehabilitation outpatient clinic of the Agostino Gemelli University Hospital of Rome between May and October 2022. Part of these patients has been included in our previous study.10 The present study complies with the STROBE guidelines. Eligibility criteria The inclusion criteria were a diagnosis of PD according to the criteria of the Brain Bank of London; Hoehn and Yahr stage II-III; absence of cognitive impairment (MMSE> 24/30); effective pharmacological control of the pathology; acceptance and signature of informed consent. The exclusion criteria comprised: a diagnosis of atypical Parkinsonism; presence of a clinically diagnosed Pisa syn- drome, poor pharmacological compensation of the disease; diagnosis of other neurological, neuromuscular diseases or osteo-articular pathologies; visual impairment or vestibular disorders. Clinical evaluation Medical examination Patients that met the inclusion criteria underwent a medical examination during which anamnestic data were collected regarding the age, weight, height, Body Mass Index (BMI), disease duration and current PD treatment including daily dose of Levodopa. All the patients were examined in the morning during the “ON” pharmacological phase. Cervical pain was assessed during the medical examination by ad- ministering both the pain Visual Analogue Scale (VAS) and the McGill pain questionnaire. The patient was classified as having pain if cervical pain was reported in at least in one of the two questionnaires. Radiographic evaluation Each patient underwent a standard whole-spine X-ray in two planes (antero-posterior and lateral) in orthostatism. A senior radiologist evaluated the radiological images for the presence of spinal scoliosis and other deformities. To avoid misinterpretation with Pisa syndrome, which is a reversible lateral bending of the trunk, scoliosis was defined as the presence of a radiographic Cobb’s angle of at least 10° on the coronal plane, with or without vertebral rotation, that is not corrected by passive movement or supine position.3 The curve was classified according to the location of its apex (most lateral vertebra) and its extremities (most peripheral upper and lower vertebrae), the direction of the convexity (right or left) and the curvature range (broad or narrow). The presence of other pathological findings in the coronal (e.g., compensation curve) or sagittal plane (e.g., kyphosis, lordosis, listhesis, etc.) was also reported when present. Stabilometric evaluation Static balance was assessed through a standardized stabi- lometric exam performed on a ‘Prokin PK 254 P’ device produced by TecnoBody Srl. (Dalmine, BG, Italy). The device consists of a static platform (47 cm in circumfer- ence) with four piezoelectric sensors positioned at the ex- tremities of the four cardinal points. The temporal resolution was 0.01 seconds, and the sampling frequency was set at 20 Hz. The patients were asked to stand on the platform for 60 seconds in a neutral position with the feet forming a 30-degree angle. The test was carried out 30 seconds with the eyes open and 30 seconds with the eyes closed. All data were analysed using ProKin 36 software to calculate the centre of pressure (CoP) sway on the X (anterior-posterior) and Y (medio-lateral) axes (mm), the CoP velocity on the X (anterior-posterior) and Y (medio- lateral) axes (mm/s), the sway path perimeter (mm), and the area of the ellipse (mm2). Lower values reflect greater control in maintaining static balance. We considered as primary outcome the reduction of the length of adaptive movements of the following variables: i) SwayAP and SwayML (mm): standard deviation of CoP time series along the anterior-posterior and medio-lateral axes; ii) Ve- locityAP and VelocityML (mm/s): velocity of oscillations along the anterior-posterior and medio-lateral axes; iii) Perimeter (mm): total length of CoP trajectory; iv) Area (mm2): area of the 95 % confidence ellipse;11 v) Romber- gArea: ratio between the value of the area with the eyes closed and with the eyes open. Dynamic balance Dynamic balance was evaluated using the Tinetti, the Berg Balance scale (BBS) and the Short Physical Performance Battery (SPPB): i) the Tinetti scale is a 16-item standardized screening modality for gait and balance disorders in elderly patients and patients with PD. The scoring system ranges from 0 to 28. The higher the score, the lower the risk of falls;12 ii) the BBS is a 14-item scale used to test patients with balance problems, validated in PD; iii) the score ranges from 0 to 56 and does not include gait assessment. The lower the score, the greater the risk of falling;13 iv) the SPPB is used to assess functional mobility in elderly patients or individuals affected by neurological diseases. It includes 3 subsets (walking, sit-to-stand and balance). The score ranges from 0 to 12; the lower the score, the lower the func- tional ability.14 The study was carried out according to the Declaration of Helsinki and the protocol was approved by the Ethics Com- mittee of the Policlinico Gemelli Foundation (UCSC prot. N 5492/14, 05.03.2014). All patients provided their in- formed consent prior to inclusion in the study. Statistical analysis Per-protocol analysis was carried on. Statistical analyses were performed using Statistic Package for Social Sciences - 28 - Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 (SPSS) version 25.0. Data for categorial variables were ex- pressed as absolute numbers and percentage and the Fisher exact or X2 tests were used to compare them. Continuous variables were expressed as mean, standard deviation (SD) and minimum and maximum value. Due to the small sample size, it was assumed a priori that the distribution of the con- tinuous variables was non-normal. For this reason the Mann- Whitney test was used to compare the variables examined between the two groups. Linear univariate and multivariate and logistic regression model analysis were performed to provide an adjusted assessment of factors potentially asso- ciated with the presence of scoliosis in patients with PD. Results A total of 16 patients affected by PD were assessed for pres- ence of scoliosis (8 males and 8 females). Half of them met the criteria for scoliosis3 and were classified as the “true scoliosis” group (TS); the other half presented a Cobb’s angle of less than 10° and were defined as the “non-scolio- sis” group (NS). Table 1 summarizes the clinical and de- mographic characteristics of the patients. Detailed clinical presentation and demographic differences at enrollment be- tween men and women are presented in the Appendix (Table 1). The average age of men 76.75 ± 4.29 was higher than women 64.13 ± 9.82 (p-value < 0.05). The NS group presented a thoracic spinal deviation below the cutoff angle for diagnosing scoliosis. In one case we found a significant dorsal kyphosis (55°) and in another case a grade I retrolisthesis of T2 over L2. In the TS group, except for one patient who presented a severe scoliosis (50.15°), all the other patients presented a mild form sco- liosis with a Cobb’s angle ≤ 20°. In most cases the curvature was lumbar and broad range. Other spinal abnormalities ob- served included one case of listhesis and two cases of ver- tebral fracture. Details about the radiological characteristics of the patients are displayed. Frequency of neck pain re- vealed a prevalence of 37.5% (n=3) in the NS group com- pared to 50% (n=4) in the TS group, however it was not possible to reject the null hypothesis. Also, any difference in cervical pain severity was observed between groups in both the VAS and in the McGill scores (Table 1). Subgroup analysis showed that subjects with a disease du- ration less than 48 months had a higher prevalence of neck pain compared to those with a disease duration longer than 48 months (n=6; 75.0% vs n= 1; 12.5%; P-value <0.05). Static balance evaluation difference between the TS group and the NS group are shown in the upper part of Table 2. Likewise, dynamic balance evaluation difference between the TS group and the NS group are shown in the lower part of Table 2. Detailed differences regarding the clinical as- sessment of static and dynamic balance between men and women are shown in the Appendix (Table 2A). Linear regression models did not show any worthy of at- - 29 - Table 1. Clinical and demographic characteristics of the patients and evaluation of cervical pain according scolio- sis classification. Non-Scoliosis True Scoliosis P value (N=8; 50%) (N=8; 50%) Mean±SD (min - max) Mean±SD (min - max) Sex (male/female) 6 (75%) / 2 (25%) 2 (25%) / 6 (75%) 0.13a Age (years) 70.63±10.20 (55–82) 70.25±10.87 (53–81) 0.964b BMI (kg/m2) 26.00±2.90 (23–31) 25.16±3.75 (21–32) 0.50b Length of disease (months) 66.00±32.14 (20–112) 76.00±75.26 (28–232) 0.69b UPDRS score 20.25±6.20 (9–28) 24.43±13.39 (9–44) 0.61b H & Y classification 1.69±0.26 (1.50–2.00) 1.929±0.70 (1.50–3.00) 0.61b LEDD (mg/day) 456.25±247.04 (100–800) 450.00±386.22 (0–1000) 0.87b Number of drugs 2.38±1.06 (1–4) 2.14±1.06 (1–4) 0.35b VAS cervical 2.50±3.50 (0–8) 3.75±4.02 (0–8) 0.50b McGill cervical 6.88±9.70 (0–21) 8.88±10.43 (0–26) 0.80b Reported pain/non-reported pain 3 (37.5%) / 5 (62.5%) 4 (50%) / 4 (50%) 0.99a BMI, Body Mass Index; UPDRS, Unified Parkinson’s Disease Rating Scale; LEDD, Levodopa Equivalent Daily Dose. aFischer Test; bMann-Whitney Test. Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 tention association between the Cobb’s angle and the SPPB total, Tinetti scale, BBS or other stabilometric parameters (Table 3). Detailed graphic representa-tion of the distribu- tion of the studied models relating to the Cobb’s angle are present in the appendix via scatterplot (Figure 1). Patients with scoliosis showed a lower variability of the perimeter but a higher variability of the area at the Rom- berg index compared to the SA group. Also, linear regression models showed no association be- tween cervical pain (respec-tively VAS score and Mc Gill score) and the SPPB total, Tinetti scale, BBS or other sta- bilometric parameters (Table 4). Detailed graphic rep- resentation of the distribution of the studied models relating to VAS score and Mc Gill score are present in the appendix via scatterplot (respectively Figure 2 and 3). Furthermore, patients with neck pain showed a lower vari- ability of the Romberg index (both area and perimeter) than patients without neck pain. - 30 - Table 2. Clinical evaluation of static and dynamic balance according scoliosis classification. Non-Scoliosis True Scoliosis P value (N=8) (N=8) Mean±SD (min - max) Mean±SD (min - max) SPPB Equilibrium 3.13±0.64 (2–4) 3.00±1.00 (2–4) 0.87b SPPB Gait 4.00±0.00 (4–4) 3.43±0.78 (2–4) 0.19b SPPB Sit-to-stand 3.13±0.64 (2–4) 2.43±1.51 (0–4) 0.46b SPPB Total 10.25±1.03 (9–12) 8.86±3.02 (5–12) 0.53b Tinetti 24.13±1.12 (22–26) 21.14±4.18 (12–24) 0.03b BBS 47.00±1.60 (45–50) 45.29±5.09 (37–52) 0.46b Eyes open Sway AP (mm) 3.13±1.24 (1–4) 3.50±1.60 (2–6) 0.99b Sway ML (mm) 2.38±1.50 (1–6) 3.00±1.77 (1–7) 0.19b Velocity AP (mm/s) 9.25±5.82 (3–18) 7.38±2.82 (4–13) 0.72b Velocity ML (mm/s) 5.25±1.75 (3–7) 4.87±1.53 (3–7) 0.72b Perimeter (mm) 279.88±143.61 (114–496) 237.50±74.91 (158–387) 0.72b Area (mm2) 145.75±108.42 (32–383) 183.25±150.85 (59–490) 0.50b Eyes closed Sway AP (mm) 5.25±2.60 (1–10) 5.50±1.69 (4–8) 0.96b Sway ML (mm) 3.25±1.83 (2–7) 3.38±1.68 (1–6) 0.80b Velocity AP (mm/s) 26.25±28.68 (5–94) 17.38±10.48 (7–37) 0.72b Velocity ML (mm/s) 9.62±7.02 (4–26) 9.13±4.97 (4–20) 0.96b Perimeter (mm) 705.38±723.49 (153–2411) 509.50±287.25 (196–963) 0.88b Area (mm2) 393.88±433.23 (44–1400) 334.75±194.49 (81–580) 0.88bb Romberg (EC/EO) Perimeter (mm) 2.25±1.24 (1.34–4.97) 2.05±0.83 (1.21–3.93) 0.64b Area (mm2) 2.75±2.75 (1.34–9.52) 2.24±1.44 (1.01–5.34) 0.78b bT-student test. Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 - 31 - Table 3. Association between Cobb’s angle and the Tinetti scale, SPPB, BBS or other stabilometric parameters. Cobb’s angle Univariate P-Value R Squarea Multivariate P-Value R Squareb Models1 Models2 Unstandardized Unstandardized B coefficients B coefficients SPPB Total -0.39±1.69 0.82 0.01 -0.51±2.21 0.82 0.56 Tinetti -0.49±1.16 0.68 0.02 0.17±3.15 0.96 0.52 BBS -0.79±0.94 0.42 0.05 -0.03±1.10 0.98 0.55 Perimeter (EC/EO) 4.68±2.93 0.13 0.15 4.84±2.97 0.15 0.69 Area (EC/EO) 1.55±1.47 0.31 0.07 1.27±1.68 0.48 0.59 1Unadjusted model; 2Adjusted model for age, sex, disease duration, BMI; LEDD (mg/day) and VAS score; aR Square for univariate models; bR Square for multivariate models. Table 4. Association between cervical pain and the Tinetti scale, SPPB, Berg balance or other stabilometric pa- rameters. VAS score Univariate P-Value R Square Multivariate P-Value R Square Models Models Unstandardized Unstandardized B coefficients B coefficients SPPB Total 0.36±0.43 0.43 0.05 0.62±0.44 0.29 0.904 Tinetti 0.25±0.29 0.41 0.05 1.05±0.72 0.28 0.908 Berg Balance 0.15±0.27 0.59 0.02 0.36±0.28 0.33 0.895 Perimeter (EC/EO) -1.08±0.92 0.26 0.09 -1.88 ±0.60 0.88 0.968 Area (EC/EO) -0.49±0.44 0.28 0.08 -0.59±0.29 0.17 0.939 Mc Gill score Univariate P-Value R Square Multivariate P-Value R Square Models Models Unstandardized Unstandardized B coefficients B coefficients SPPB Total 1.11±1.22 0.38 0.060 1.36±1.41 0.44 0.888 Tinetti 0.72±0.84 0.41 0.053 2.27±2.32 0.43 0.890 Berg Balance 0.48±0.76 0.54 0.029 0.72±0.91 0.51 0.876 Perimeter (EC/EO) -2.78±2.43 0.27 0.086 -5.26±1.41 0.06 0.980 Area (EC/EO) -1.31±1.17 0.28 0.082 -1.77±0.62 0.10 0.968 Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 - 32 - Figure 1. Scatter plots of association between Cobb’s angle and the SPPB total, Tinetti scale, BBS or other stabilomet- ric parameters, univariate (left) and multivariate models (right). Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 - 33 - Figure 2. Scatter plots of association between VAS score and the SPPB total, Tinetti scale, BBS or other stabilometric parameters, univariate (left) and multivariate models (right). Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 - 34 - Figure 3. Scatter plots of association between MC Gill score and the SPPB total, Tinetti scale, BBS or other stabilomet- ric parameters, univariate (left) and multivariate models (right). Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 Discussion Postural deformities including scoliosis tend to occur more often in PD than in the general elderly population.2,15 Scoliosis and abnormal posture can produce any type of joint pain and exacerbate the overall sensory impairment and the risk of falls in PD.15 Static and dynamic balance normally rely on the sound integration of visual, vestibu- lar, and proprioceptive sensory information within the basal ganglia and on a coordinated reflex and motor ac- tivity.16 Many studies have demonstrated that patients with PD have subnormal integration of peripheral sensory sti- muli with greater reliance on the visual input during static and dynamic motor tasks.3,16 Furthermore, the devel- opment of balance problems and falls is typically indi- cative of disease progression and worse prognosis.17 In our study, static and dynamic balance evaluation did not reveal any important differences between the TS and the NS group. The regression models highlighted that the demographic and clinical characteristics of the patients can significantly influence the dynamic balance assessment questionnaires, but this evidence does not translate into worse stabilometric data in those who had a greater Cobb angle. This could in- dicate that scoliosis, neck pain and postural imbalance do not have a linear association between them. The severity of PD and the severity of scoliosis are able to influence dy- namic imbalance and risk of falling, but this association still needs to be further studied to identify whether the two con- ditions together determine an increased risk compared to these two risk factors considered individually. The literature does not provide any data regarding a pos- sible correlation between scoliosis and balance problems in PD so that the only comparison can be done with individ- uals with idiopathic scoliosis and no PD. In this regard, pre- vious studies have shown a significant correlation between scoliosis and static imbalance in adolescents with moderate idiopathic scoliosis compared to the healthy controls.18,19 Furthermore, patients with high major curves had a better postural stability than those with low major curves.20 Re- garding the correlation between scoliosis and dynamic im- balance, compared to healthy controls, Shirado et al.21 found a significant lower weight’s shift in the patients with idiopathic scoliosis during both slow and fast side-shifts. Furthermore, weight’s shift was less on the concave side than on the convex one. Another study by Haber et al.22 sug- gests that scoliotic subjects have a slower speed of gait due to a shorter stride length and a longer stride time. Moreover, they display variations in the timing of muscle activation. Also in this case, to the best of our knowledge, no study in- vestigated the correlation between scoliosis and walking problems in PD. This correlation should be further explored in future studies. Literature data on neck pain prevalence are currently in- sufficient both in PD patients and in individuals with id- iopathic scoliosis. The study of Kim et al.23 is the only one reporting a prevalence of neck pain of 5.5% in a cohort of 400 patients with PD, while the study of Topalis et al.6 is the only one reporting a prevalence of cervical pain of 42% in adults with idiopathic scoliosis. In our study the prevalence of cervical pain was of 50% in PD patients with scoliosis and 37% in those without scoliosis. Regard- ing the severity of cervical pain, the average VAS and McGill score was tendentially higher in the TS group compared to the NS group. However, this data did not reach a statistical significance. In contrast, subgroup anal- ysis stratified by disease duration showed that individuals with a disease duration >48 months seem to experience less cervical pain compared to patients with more recent onset of the disease. This data is in contrast with the study of Silverdale et al.24 in which disease duration was not found to influence pain severity in a cohort of 1957 par- ticipants with early/moderate PD. Regarding the correla- tion between neck pain and balance problems, subjects with neck pain did not reveal any difference in dynamic and static balance parameters compared to those without it. Like for scoliosis and neck pain, also in this case we did not find any literature data that investigated this kind of relationship in PD patients. However, if we look at the general population, a study of Ruhe et al.8 suggests that individuals with neck pain display diminished propriocep- tion and impaired postural control. Limitations of the study This study has a few limitations that should be noted. First, the small sample size and the lack of a control group with- out PD limit the power of our observation. Second, we per- formed the clinical assessment at the “ON” phase which could have masked the real level of functional disability and pain of the patients. Third, we did not assess the dura- tion of cervical pain in the group of patients who reported it which could have been useful to make further correlations with balance impairment. Conclusions Scoliosis, cervical pain and postural imbalance are signifi- cant yet often overlooked complaints of PD. Early detection and accurate screening could minimize potential pain and suffering and increase the quality of life. Our results did not show a clear association between scoliosis, cervical pain, and static and dynamic imbalance in PD. However, patients with a disease duration of less than 48 months appear to show a greater frequency of cervical pain. Given the limi- tations of our study and the paucity of the literature on this subject, further studies are needed to clarify these prelimi- nary findings. List of abbreviations PD, Parkinsons’s disease NS, non-scoliosis TS, true scoliosis BMI, Body Mass Index BBS,Berg Balance scale VAS, Visual Analogue Scale CoP, centre of pressure SPPB, Short Physical Performance Battery SPSS, Statistic Package for Social Sciences SD, standard deviation UPDRS, Unified Parkinson’s Disease Rating Scale LEDD, Levodopa Equivalent Daily Dose - 35 - Non -co mmerc ial us e o nly Scoliosis, cervical pain and postural imbalance in Parkinson’s disease Eur J Transl Myol 34 (2) 12354, 2024 doi: 10.4081/ejtm.2024.12354 Conflict of interest The authors declare no potential conflict of interest, and all authors confirm accuracy. Funding This study was supported and funded by the Italian Ministry of Health-Ricerca corrente. The founders had no role in study design, data collection and analysis, publication deci- sion, or manuscript preparation. Ethics approval and consent to participate The study was carried out according to the Declaration of Helsinki and the protocol was approved by the Ethics Com- mittee of the Policlinico Gemelli Foun-dation (UCSC prot. N 5492/14, 05.03.2014). All patients provided written in- formed consent prior to inclusion in the study. Consent for publication All patients provided written informed consent for publica- tion prior to inclusion in the study. Availability of data and materials Not applicable Correspondence Mariantonietta Ariani, Department of Neurosciences, Sense Organs and Thorax, Catholic University of the Sacred Heart, 00168, Rome, Italy. ORICD ID: 0009-0001-3061-3575 E-mail: mariantonietta.ariani01@icatt.it Gianpaolo Ronconi ORICD ID: 0000-0002-7310-093X E-mail: gianpaolo.ronconi@policlinicogemelli.it Dario M. Gatto ORICD ID: 0000-0002-9664-0779 E-mail: dario.gatto90@gmail.com Sefora Codazza ORICD ID:0009-0004-0282-2822 E-mail: sefora.codazza@guest.policlinicogemelli.it Fabio Ingravalle ORICD ID: 0000-0001-6295-9848 E-mail: fabio.ingravalle@gmail.com Giorgio Ferriero ORICD ID: 0000-0002-7873-6777 E-mail: giorgio.ferriero@icsmaugeri.it Daniele Coraci ORICD ID: 0000-0002-7019-9006 E-mail: danielecoraci@aol.com Paola E. Ferrara ORICD ID : 0000-0002-1903-3449 E-mail: paolaemilia.ferrara@policlinicogemelli.it References 1. Ashour R, Jankovic J. Joint and skeletal deformities in Parkinson’s disease, multiple system atrophy, and pro- gressive supranuclear palsy. Movement Disorders 2006;21:1856–63. 2. Alwardat M, Schirinzi T, Di Lazzaro G, et al. The effect of postural deformities on back function and pain in pa- tients with Parkinson’s disease. NeuroRehabilitation 2019;44:419–24. 3. Doherty KM, van de Warrenburg BP, Peralta MC, et al. Postural deformities in Parkinson’s disease. 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