Postural Awareness in Parkinson’s Disease

This doctoral dissertation investigated postural awareness in Parkinson’s disease (PD) as a subjective dimension linking neuropsychological mechanisms, body experience, and clinical outcomes. Chapter I provided the theoretical foundation, framing postural instability as a “dopamine-resistant” syndrome arising from interactions among biomechanical, sensory, cognitive, and affective factors rather than solely from dopaminergic or motor dysfunction. Evidence implicates fronto-parietal, insular, and cingulate regions in integrating attention, interoception, and emotional regulation with postural strategies, suggesting that postural awareness may be a clinically relevant and potentially modifiable construct. Building on this framework, Chapter II presented the first empirical operationalisation of postural awareness in PD through the Postural Awareness Scale (PAS). Two small cohorts of Italian and Spanish PD patients were assessed to examine feasibility, psychometric properties, and construct validity. PAS distributions were adequate, with no ceiling or floor effects, and construct validity showed theoretically coherent patterns. The Ease/Familiarity factor (F1) correlated positively with mindfulness and negatively with pain, dysmorphic concerns, and depressive symptoms, and was uniquely predicted by fear of falling and depression, highlighting its clinical relevance. The Need for Attention Regulation factor (F2) yielded less stable results, potentially reflecting compensatory vigilance. Cross-cultural comparisons revealed higher scores in the Spanish cohort, although differences were mainly attributable to reverse-coded item effects rather than genuine cultural variance. Secondary analyses explored associations between PAS factors and neuropsychological as well as affective–behavioural domains, aiming to clarify the cognitive and emotional substrates of postural awareness. Chapter III broadened the scope by conducting a scoping review of mindfulness- and yoga-based interventions in PD, focusing exclusively on Movement Disorder Society–recommended postural measures such as the Mini-BESTest, PIGD score, and dynamic posturography. Seven studies met inclusion criteria: yoga interventions consistently improved dynamic balance with changes exceeding minimal clinically important differences, while a mindfulness pilot and a hybrid meditation–movement protocol showed promising but limited evidence. However, none assessed subjective postural awareness, underscoring a critical measurement gap. Across chapters, the findings converge on the importance of integrating subjective and objective assessments of posture. While preliminary due to small sample sizes, results support the feasibility of PAS in PD and suggest that postural awareness occupies a unique position at the intersection of attentional control, affective regulation, and balance confidence. Future research should include large, multicentre, longitudinal, and interventional studies to test PAS responsiveness and predictive validity. Overall, this thesis positions postural awareness as a potentially modifiable target and meaningful outcome for holistic, person-centred rehabilitation in Parkinson’s disease.