What's Hot in PD? Is it Time to Start Paying Attention to Pain Symptoms in Parkinson’s Disease Patients?

Why is it that when we survey patients with Parkinson’s disease they frequently report pain, yet most neurologists and practitioners fail to address it or alternatively sweep it under the carpet?  Shockingly, the more that comes to light about pain in Parkinson’s disease, the more exposed and embarrassed we as a medical profession should be.  Blair Ford, a movement disorders neurologist at Columbia University in New York city, nailed it precisely by titling his recent review of the subject, “Pain in Parkinson’s Disease: The Hidden Epidemic.”

Beiske and colleagues recently reviewed the prevalence and characteristics of Parkinson’s disease pain, and their findings were impressive and worrisome especially for those caring for Parkinson’s disease patients.  The results revealed that “pain was reported by 146 (83%) patients. And compared to the general population, the Parkinson's disease patients experienced significantly more pain. Fifty-three percent of the patients reported one, 24% reported two and 5% reported three pain types. Musculoskeletal pain was reported by 70%, dystonic pain by 40%, radicular-neuropathic pain by 20% and central neuropathic pain by 10%. Pain was frequent and disabling, and a minority of the Parkinson's disease patients with pain received analgesic medication.”  Similarly in the recently published PRIAMO study (July 2009), in over 1000 Parkinson’s disease patients studied, leg pain was reported in 38%.

It is well known among experienced Parkinson’s disease clinicians that some pain is responsive to levodopa. Therefore, many practitioners attempt to titrate dopaminergic medication doses before erroneously concluding that pain was related to another condition (e.g. a slipped disc in the back, or arthritis, etc.).  Nebe and colleagues recently published a paper where they discovered that “ratings for pain intensity were increased during “off” dopaminergic periods. Secondary pain possibly related to lumbar disc (e.g. back) degeneration was common. Interestingly this secondary pain was relieved but not completely abolished by levodopa.”  This preliminary data is suggestive that even if dopaminergic replacement does not abolish pain, it may be a helpful treatment modality.

All of these recent findings strongly suggest that pain is common and undertreated in Parkinson’s disease patients.  Pain in this population may or may not be due primarily to the Parkinson’s disease, but in many cases it may have a partial response to dopaminergic therapy.  There are no standardized approaches to the treatment of Parkinson’s disease pain, but we usually advocate an interdisciplinary approach, similar to what is currently employed for other Parkinson’s disease symptoms (with the exception that in severe cases we may add a pain management specialist to interface with the Parkinson’s disease case team).  It is important if you have Parkinson’s disease and you are experiencing pain that you immediately report this symptom and the details regarding this symptom to your doctor.  Don’t worry about “being a pain,”  as it has become all too obvious we have been ignoring Parkinson’s disease pain in too many patients for too long!

 

References:

Ford B. Parkinson disease: Pain in Parkinson disease: the hidden epidemic. Nat Rev Neurol. 2009 May;5(5):242-3.

Beiske AG, Loge JH, Rønningen A, Svensson E. Pain in Parkinson's disease: Prevalence and characteristics. 2009 Jan;141(1-2):173-7. 2008 Dec 18.

Barone P, Antonini A, Colosimo C, Marconi R, Morgante L, Avarello TP, Bottacchi E, Cannas A, Ceravolo G, Ceravolo R, Cicarelli G, Gaglio RM, Giglia RM, Iemolo F,Manfredi M, Meco G, Nicoletti A, Pederzoli M, Petrone A, Pisani A, Pontieri FE, Quatrale R, Ramat S, Scala R, Volpe G, Zappulla S, Bentivoglio AR, Stocchi F, Trianni G, Dotto PD; on behalf of the PRIAMO study group. The PRIAMO study: A multicenter assessment of nonmotor symptoms and their impact on quality of life in Parkinson's disease. Mov Disord. 2009 Jun 9.

Nebe A, Ebersbach G. Pain intensity on and off levodopa in patients with Parkinson's disease. Mov Disord. 2009 Jun 15;24(8):1233-7.

You can find out more about our National Medical Director, Dr. Michael S. Okun, by also visiting the Center of Excellence, University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life and 10 Breakthrough Therapies for Parkinson's Disease.

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