Revisiting Pain In Pdthe 50 Shades Of Pain Experienced By Parkinsons Patients
Pain is a quality of life issue for people with Parkinsons disease and can be under treated by doctors who may assume that is worsens as the disease progresses, although for some pain is an initial symptom of PD. This article helps focus your physicians attention in the right direction to accurately diagnose your pain.
Q What Is The Pain Experience In Pd And Does It Differ Between Genders
Dr. Fleisher: As with almost everything else in PD, the pain experience is highly individualized, and no 2 people, regardless of gender, will have the same symptoms. Female gender appears to be an independent risk factor for chronic pain in PD, even though PD is more common in men than in women.2 Pain intensity also is higher in women than in men with PD.1
There is a lot of interesting research examining the contributions of hormones to the greater prevalence of PD in men or, conversely, the lower prevalence in women.3 Once we better understand the roles of sex hormones in the pathophysiology of PD, we may better understand whether hormones also play a role in the higher incidence of with PD.
What Can I Do On A Regular Basis To Manage My Pain
Remember, youre your best advocate as you understands how your pain feels. Understanding and communicating the kind of pain youre experiencing can greatly inform your treatment plan and will allow your doctors to address the type and severity of your specific pain. Keep your care team informed about activities that cause pain or the times of day your pain is worst so they can help fine-tune your care plan. Do you notice the pain starting to creep in at a certain point after you take your medication? Do you feel fine when you bike but experience pain when you jog? Did you start experiencing this pain before or after your Parkinsons diagnosis? Taking stock of these sorts of questions can be helpful as you work with your care team to effectively treat your pain.
Incorporating approved medications and following the pain ladder can also help you find the right pain management solution, as can taking steps in your everyday life to be an active participant in your own pain management. Regular stretching, heat and cold treatments, exercise, yoga, and dance can all help reduce your pain, and they are all steps that you can take on your own. Making adjustments to your home and workspace, such as minimizing places where fall risks are likely, using an ergonomically designed desk, sleeping in a comfortable bed, and wearing clothes and shoes that dont exacerbate pain, can help you establish a more pain-free daily routine.
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Pathological Links Between Pd And Persistent Pain
Do central processing abnormalities act as a catalyst for developing persistent pain in PD? And are they linked to those acting as a catalyst for the development of PD itself? We know that maladaptive central nervous system plasticity underlies the aetiology of PD, while multiple lines of evidence demonstrate that one important mechanism underpinning varied persistent pain states is maladaptive plasticity in central descending inhibitory pathways. Unique descending inhibitory pathways, including diffuse noxious inhibitory controls , are sub-served by monoaminergic neurotransmission,, and monoaminergic neurotransmission is affected by PD-specific neurodegenerative changes already at the prodromal stage of the disease. It is possible that there is a link between an underlying mechanism of PD and the development of persistent pain, where an established link could be therapeutically targeted thus improving not only the level of pain experienced by the affected individual, but also PD progression. Performing the appropriately powered human psychophysics pain experimental quantification studies would have the potential to contribute to our understanding of how the nervous system acts endogenously to modulate pain perception in PD, reveal whether this is linked to the aetiology of PD, and therefore unveil targets for intervention in the management of chronic pain in a personalised manner.
Specific Pain Syndromes In Pd
Orthostatic hypotension can cause headache or neck pain . If necessary, antihypertensive co-medication should be adjusted in accordance with recently given recommendations . Additional measures are physical exercises, fluid intake, wearing of compression stockings class two, and administration of substances such as midodrine, fludrocortisone or, in severe cases, L-threo-3,4-dihydroxyphenylserine . Camptocormia is often accompanied with pain. Prior to therapy the cause has to be differentiated . In addition to the use of pain killers, the focus is on physiotherapy. There is no specific pain medication recommended currently.
Migraine is reported less often in PD, and often associated with depression and sleep disturbances . Therefore the therapy has to focus on the comorbidities as well. The usual medication for migraine can be used, but due to an increased risk for orthostatic hypotension in PD, caution should be exercised with beta blockers .
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Pain In Parkinsons Disease: A Spotlight On Women
This 2-page interview with neurologist, Dr. Jori E. Fleisher, discusses pain in Parkinsons disease with some interesting statistics about women and pain. Dr. Fleisher outlines the 4 primary types of pain in PD, how depression interferes with pain management, the role of exercise and medications in pain management as well as alternative therapies.
Q What Is The Role Of Depression In The Pain Experience In Pd
Dr. Fleisher: Depression is one of the most overlooked symptoms of PD, and it can affect over 30% of people with the disease at some point in their illness.5 I think there is a misconception that depression results from an adjustment disorder following diagnosis. While that may be partially true, patients with PD have alterations in various neurotransmittersincluding serotonin and norepinephrine in addition to dopaminethat predispose them to depression.6,7
Depression is the primary factor related to quality of life in PD and is an independent risk factor for medication nonadherence. A physician could prescribe the most comprehensive regimen to control Parkinsons symptoms, including pain, but if depression symptoms are not being addressed simultaneously, the likelihood that that person is going to take that regimen is pretty minimal.
Given the link between depression and chronic pain, patients who are depressed should be screened for chronic pain and vice versa. In my practice, we screen every patient with the Unified Parkinsons Disease rating scale , which has both a patient-reported subjective component that includes questions about depression, pain, and altered sensation, as well as an objective component that includes a physical examination and questions about potential medication adverse effects . The patient fills out the subjective component every single time they come to the office.
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Pathophysiological Pathways Of Pain In Pd
The origin of pain in PD remains poorly understood. At times, it appears as dystonia when the dopaminergic effects wear off. The pathophysiological mechanisms behind this phenomenon are most probable by which dopamine, in the network with other monoamines such as noradrenaline and 5-hydroxytryptamine , interacts through inhibitory and excitatory pathways. Abnormalities in descending pathways affect central pain processing. In addition, clinically registered neuropathic pain and other muscular pain sensations are described by PD patients. This has led to the exploration of pathways other than those secondary to rigidity, tremor, or any other motor manifestations of the disease, with abnormal nociception processing in PD patients suffering from pain as the most likely suspect. The basal ganglia process somatosensory information in different ways, and increased subjective pain sensitivity with lower electrical and heat pain thresholds has been reported in PD patients. This abnormal processing also comprises PD-related disorders such as multiple system atrophy, which exhibits almost the same prevalence of pain as PD.
The pathophysiological basis of sensory disturbances in PD, the so-called pain matrix with information from different loci, processed in the BG.
Abbreviations: PD, Parkinsons disease BG, basal ganglia GPe, globus pallidus externa, GPi, globus pallidus interna STN, subthalamic nucleus.
Leg Pain And Parkinson’s
Interestingly enough, one of my early symptoms of the disease was deep searing pain in my left leg, the type of pain my grandma had complained about many times. Initially this type of pain was worst in the morning as well as at night, making me think is was some sort of fasciitis. However not only did typical anti-inflammatories and muscle relaxants not alleviate my pain but pain worsened over time to a constant burning pain that felt as if someone was tearing the muscle and pouring hot oil on it. The pain was so excruciating it was permeating into all aspects of my life. I was constantly in need of deep tissue massage asking my husband to massage my legs just as my grandmother had asked of us time and time again. This helped only temporarily.
Which brings me to the four types of leg pain in PD.
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Standardised Testing And Powered Cohorts
Future research should control for confounding factors by standardising variables across laboratories. For example, the presence of pain should be classified according to an internationally validated scale, e.g. the KPPS. PD sub-types should be standardised according to an internationally verified method. Although there is no gold standard for sub-type classification, distinctions have been made between tremor-dominant and non-tremor-dominant sub-types, and by using UPDRS-III sub-type-based classifications. It is recommended that future studies should classify sub-types according to the German AWMF guidelines .
Fluctuations Of Pain Experiences In Pd
Patterns of NMS fluctuations are heterogeneous and complex. Psychic NMS seem to fluctuate more frequently and severely than nonpsychic symptoms. A recent study of ten frequent NMS in advanced PD using VAS rating scales in motor-defined on- and off-states, as well as self-ratings at home, confirmed previous suspicions that increased pain in off-states and pain fluctuations correlate with a low health-related quality of life. Pain as NMS was more frequent in the off-state more precisely, it was three to four times more common during the off-state than during the on-state.
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Pain Management Principles In Parkinson’s Disease
Non-pharmacologic methods with a multidisciplinary pain team should be utilized to provide optimal multimodal treatment in patients with PD.4 Muscle relaxation exercises and walking regularly can improve flexibility and dampen experiences of pain associated with motor symptoms.6 Rehabilitation with a physical therapist can improve gait and balance, targeting pain caused by motor symptoms. Surgical interventions, such as deep brain stimulation or an implanted spinal cord stimulator, may be appropriate for those patients experiencing pain with PD who do not respond to pharmacologic or rehabilitation interventions.1,6,9
Optimization of treatment with levodopa and other antiparkinsonian medications should be the first pharmacological step in managing PD-related pain.6,8 Beyond this recommendation, no evidence encourages the use of specific analgesic agents in any stepwise order, making patient input and assessment of pain type critical to appropriate treatment.
Patients should be prescribed analgesics if optimization of dopaminergic agents is not effective on its own .4
Optimization of Dopaminergic Agents
Safinamide is a selective, reversible MAO-B inhibitor that reduces degradation and reuptake of dopamine to increase levels in the striatum.19 Safinamide also has non-dopaminergic properties that modulate glutamate release via inhibition of voltage-gated sodium channels. This dual mechanism may mitigate pain, especially during off periods.
What Drug Treatments Are Commonly Prescribed For Pain
Dopamine agonists are often the neurologists first weapon to alleviate Parkinsons-related pain. Levodopa is used to treat many types of pain due to Parkinsons because it treats the motor symptoms such as rigidity and dystonia that are causing them. Other medicines called analgesics can also be used to treat pain. When talking with your doctor, it is critical to let her know about all of the medications you are taking including over the counter drugs, herbs, vitamins and mineral supplements. Without complete information, your doctor may prescribe a drug that could have serious adverse effects.
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Treatment Depends On Properly Identifying The Type
If pain is bilateral always assume it is central pain pain due to PD. In my experience Azilect works great for this type of pain. Other medications which can be employed for this pain as well.
Massage therapy works for all types of leg pain-my favorite therapy but can be costly. Water therapy may also work for all types except central pain. Physical therapy can alleviate dystonia pain, as well as musculoskeletal and radicular pain.
If pain is due to dystonia related to levodopa intake, find out when it occurs—end of dose or at peak dose. Typically adjusting medication doses will resolve problem. However, if dystonia is an initial symptom of PD, initiating treatment with levodopa will resolve. If medication adjustment does not work well for levodopa induced dystonia, another treatment option is DBS . Pain due to dystonia independent of cause can also respond well to Botox injections, as well as centrally acting muscle relaxants. To avoid and alleviate pain caused by stiff muscles, a great treatment option is activity in the form of stretching exercises—any number of activities will do such as tai-chi or yoga. For me when I start having radicular pain shooting down my leg it is time to up my levodopa dosage.
If you are having leg pain make sure to discuss it with your physician.
Types Of Parkinson’s Pain
Most of the time, discomfort in muscles and joints is secondary to the motor features of Parkinsons lack of spontaneous movement, rigidity, and abnormalities of posture what is known as musculoskeletal pain. The most commonly painful sites are the back, legs, and shoulders and it is usually more predominant on the side more affected by parkinsonism.
But there are many other categories of pain associated with Parkinsons disease. Radicular or neuropathic pain is experienced as a sharp pain that can start in the neck or lower back with radiation to arm or leg respectively and is often associated with numbness or tingling, or a sensation of coolness in the affected limb. It is usually secondary to a pinched nerve due to something like a slipped disc.
Dystonia related pain occurs as its name suggests, at times of dystonia most often experienced in the foot, neck or face and arm at different points in the dosing schedule, particularly the off phase when there is not enough dopamine replacement but can uncommonly also occur at peak-dose times. It can be one of the most painful symptoms those with Parkinsons can face.
Akathisia pain is experienced as restlessness, a subjective inner urge to move, an inability to stay still and the inherent feelings of discomfort that it brings. It is primarily experienced in the lower limbs and can often be relieved by walking around.
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Who Should I See To Discuss My Parkinsons Pain
Your first point of contact should be your primary doctor. Whether that means your family doctor, neurologist, or Movement Disorder Specialist , start by asking them how to manage your pain. They may prescribe you one of the medications listed above, offer suggestions about altering your lifestyle, or refer you to a pain specialist.
Pain management specialists are physicians with specialized training in the field of evaluating, diagnosing, and treating pain so, speaking to one of these specialists might be helpful for you. Be sure to get a referral from your primary care doctor, though, to ensure you are visiting a physician who understands the complexity of treating Parkinsons-specific pain.
Health and wellness providers like physical therapists, acupuncturists, and massage therapists can also be valuable members of your care team. Be willing to try new things and approach alternative therapies with an open mind, as no ones path with Parkinsons pain is the same. What works for someone else may not work for you and vice versa. Consider visiting different specialists to find a treatment plan that works best for you.
Pain Is A Common But Overlooked Problem In Parkinsons Disease
Pain is an often overlooked non-motor symptom of Parkinsons disease . Studies show that between 40-80% of people with PD report pain, which is likely why it is often suggested as a topic for this blog.
One of the reasons why the topic of pain and PD is difficult to address is that it is sometimes tough to discern whether a particular pain is due to PD or not. Chronic pain is such a common symptom among the general population, and people with PD are not immune to common problems as well. However, there are aspects of PD that may exacerbate the pain experienced from a common problem. In addition, there are particular types of pain that may be unique to people with PD.
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Types Of Pain Associated With Parkinsons Disease
Parkinsons disease is usually known for its motor symptoms such as tremor, slowness of movement, and stiffness. However, most people dont realize that pain is also associated with Parkinsons disease. In fact, recent research shows that it could be one of the early warning signs of the disease.
How Is Parkinsons Disease Diagnosed
Diagnosing Parkinsons disease is sometimes difficult, since early symptoms can mimic other disorders and there are no specific blood or other laboratory tests to diagnose the disease. Imaging tests, such as CT or MRI scans, may be used to rule out other disorders that cause similar symptoms.
To diagnose Parkinsons disease, you will be asked about your medical history and family history of neurologic disorders as well as your current symptoms, medications and possible exposure to toxins. Your doctor will look for signs of tremor and muscle rigidity, watch you walk, check your posture and coordination and look for slowness of movement.
If you think you may have Parkinsons disease, you should probably see a neurologist, preferably a movement disorders-trained neurologist. The treatment decisions made early in the illness can affect the long-term success of the treatment.
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