Managing pain in Parkinson's disease

Parkinson's Disease (PD) is a degenerative neurological disorder that affects movement.

The most commonly known symptoms of PD are related to movements, such as tremors, stiff movement, and gait and postural changes.

In PD, there are other non-motor symptoms as well, such as pain. Pain is one of the most frequent non-movement related complaints in patients who have PD, affecting 68 per cent to 95 per cent of patients across all stages of the disease, according to an article in the American Journal of Managed Care.

In PD, the type, timing, and location of the pain vary from individual to individual. This could also depend on the person's pre-existing condition before PD started as well.

Some individuals do not experience early onset of pain when their PD started, but experience it later as the disease progresses.

It is important to identify the cause of pain, and differentiate whether the pain experienced by the person with PD is due to the PD, or other factors, such as ageing or other pre-existing medical issues in the person.

There are different categories to classify pain experienced within the disease, as we will see below.

Types of Pain

Musculoskeletal

This is a type of pain that affects the bones, muscles, ligaments, tendons, and nerves. Some types of pain experienced in this category include arthritic pains and muscle aches. These pains may not be caused by PD, but are made more intense by PD.

For example, muscular pains can be worsened by stiff and rigid muscles and joints, which is a key motor symptom in PD. Uneven gait in PD can also put more stress on particular joints, leading to an increase in arthritic pain.

In elderly people, this pain is especially worse. Most PD sufferers are 60 years old and above.

At this age, individuals tend to experience skeletal problems, which are also experienced by people with PD as well. It is not clear whether having PD increases the risk or severity of these skeletal conditions, but the problems of PD can increase the intensity of these symptoms of skeletal problems in ageing.

Typically, these include osteoarthritis, which is the joint damage associated with wear and tear on the joints, arthritis of the spine, and disorders of the fibrous discs between the bones of the spine.

Neuropathic/radicular

This type of pain occurs when the body sends pain signals to the brain through the nerves and is not caused by an injury.

This could be due to common conditions such as a herniated disc or arthritis in the lower spine or neck, and the pain in these conditions are worsened in people with PD.

For example, with PD, some individuals may walk with a stoop at the shoulders or a bend at the waist, leading to an increase in pain for the individual.

Dystonic

Dystonia refers to uncontrollable muscle contractions, which result in slow repetitive movements and abnormal posturing.

These often accompany PD and include repetitive muscle twisting, spasms, or cramps which occur at different times of the day and in different stages of Parkinson's.

Dystonia can be very painful and usually appears where there is a decrease in brain dopamine levels, or as a side effect of treatment with levodopa, a form of medication used in PD.

Medication is taken in PD to increase dopamine levels in the brain to help with managing the PD. A decrease in dopamine levels in the brain often occurs in the morning before taking medication, or when a dose of medication is wearing off.

Observing a pattern when the "off" effects of medication occur are a way to prevent dystonia. Medication can be consumed in calculated time periods to reduce the "off" time.

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Akathisia

This refers to the sensation of restlessness, or not being able to be still. Sometimes, it is also called Restless Legs Syndrome (RLS).

Restless Legs Syndrome causes symptoms like pins and needles, and intensely painful sensations in the calves and/or legs. This can be relieved by moving the legs.

These symptoms tend to occur most during moments when the person is resting and still, such as watching television or when drifting off to sleep.

Central pain

Central pain is a pain syndrome caused by damage or dysfunction to the brain or spinal cord, and can be caused by a wide range of conditions aside from PD.

Symptoms are very varied between individuals, ranging from experiencing burning, aching, to stabbing sensations at different regions of the body.

It can be worsened by very slight changes in the person's environment, such as a light touch from fabrics or brushing away hair, or a change to a colder temperature.

As it is unclear why the pain starts, individuals with this condition often undergo a large number of tests to figure out what the pain is, only to find out the pain is central pain. This is a difficult condition to treat.

Therapies for managing Parkinson's-related pain

Managing pain related to PD involves medical or drug-related therapies, such as consuming medication like levodopa to help in alleviating the symptoms related to PD.

This has a knock-on effect on reducing the pain implicated by these PD symptoms on the body as well.

There are alternatives to using medicine to manage the pain as well, such as physical therapy and other complementary methods.

Although current treatment methods for managing pain in PD are limited, research in this area is growing, and hopefully will help us understand pain management in PD better.

Drug-related therapies

When medication is necessary, the doctor may recommend the following.

Dopamine

Dopamine is the gold standard in PD treatment for movement symptoms.

This involves its variants such as carbidopa, or levodopa (most often prescribed as Sinemet).

The doctor will recommend taking dopamine to improve the motor symptoms such as rigidity and dystonia experienced in PD, to prevent these symptoms from being permanent.

Reducing the symptoms experienced in PD will also help with pain relief, as the motor symptoms leading to greater pain in the person gets reduced.

When the dopamine is in effect, this is referred to as the "on" period for people with PD; during this period, their motor symptoms are well controlled.

When the dopamine wears off, this is referred to as the "off" period, and the person with PD will start to experience symptoms from the wearing off of the drug, which could include pain as well.

Adjusting medications to minimise the "off" time will help to reduce the pain. Reviewing the dosage and medication schedule of dopamine with the doctor will help with pain management too.

Botulinum toxin injections

This is used when pain is due to muscle spasms and dystonia. These injections assist in relaxing muscles which are flexed or having spasms. They are used in specific parts of the body, like the hands, feet, and neck.

However, these are not used in larger muscle groups, such as in postural abnormalities in the trunk.

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Non-steroidal anti-inflammatory drugs 

Non-steroidal anti-inflammatory drugs (NSAIDs) include medications such as ibuprofen and naproxen. These medications are often taken by the general population to reduce pain and can be helpful for pain experienced in PD as well.

They do not have neurologic side effects, which makes them suitable for people with PD. However, they may have other side effects, so it will be important to discuss with the doctor about taking NSAIDs.

Medication for nerve-related pain

Some medications, such as gabapentin, duloxetine, and pregabalin, are taken to treat nerve-related pains in PD. They can also be tried to see if they help with pain relief for some of the pain experienced in PD.

These medications are to be taken daily, and are typically well-tolerated by people with PD. However, they may cause side effects such as sleepiness.

Pain-relieving medication

Some pain relievers include opioids and Tylenol. Doctors usually recommend opioids only when the person is experiencing severe pain, as they can lead to more side effects, such as constipation, confusion, and drowsiness.

Opioids are usually not the first recommendation for pain management in PD. Lidoderm patches, which are patches containing a topical anaesthetic, are also helpful for pains in specific areas of the body.

Non-drug-related therapies

Physical therapy

This is the most common non-drug treatment and has been rated as one of the more effective pain management treatments by people with PD, as a study in PubMed has reported.

Physical therapy may recommend methods such as massage, therapeutic ultrasound, heat and/or ice therapy, and stretching and strengthening exercises to help with reducing the pain experienced in PD.

Acupuncture

Acupuncture is a traditional type of therapeutic method which involves inserting fine needles in various points on the body to treat physical and mental conditions.

This has been shown to reduce pain in Parkinson's Disease, although more studies are needed to determine their effectiveness in treating pain in PD.

Exercise

Exercise can strengthen bones and muscles, increase flexibility and help to improve the mood of the person with PD.

Tai Chi and Yoga are two types of exercises often recommended, as they can help to increase flexibility and reduce muscle stiffness through postures and poses. This aids in pain reduction.

Also, both exercises incorporate breathing exercises, which help the person with PD to relax and cope with the pain. Other exercises include walking, swimming, and dancing - whatever exercise the person with PD enjoys and can keep doing frequently is a good choice.

Coping with Parkinson's disease

While considering therapies to manage pain experienced in Parkinson's Disease, it is crucial to note that the therapies recommended are based on individual needs and preferences of the person with PD.

Also, the person with PD will have to participate in these therapies on a regular basis to see the benefits. Lastly, these therapies are not a cure-all, and should only be considered on an individual basis.

Every individual with PD will have a different journey and a different configuration of therapies that will suit them. Parkinson's Disease often requires comprehensive and well-rounded care to manage its motor and non-motor symptoms. 

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This was first published in Homage.