Treatment for Pain in Parkinson’s patients: by Dr. De Leon

According to my research, laughter is the best medicine, giggling is good for mild infections, chuckling works for minor cuts and bruises, and snickering only makes things worse.

Recently I wrote about how 85% of PD patients suffer from pain in my last blog titled “Revisiting Pain in PD: the 50 Shades of Pain Experienced by Parkinson’s Patients” in which I explained that PD patients may experience 5 types of pain syndromes:

All can occur in one person at any given time and sometimes may have more than one type of pain concomitantly!

  1. Central pain (rare; CAN be INITIAL PD symptom presentation)-dull ache all over!!
  2. Musculoskeletal pain- throbbing
  3. Nerve root pain- electrical
  4. Dystonia- cramping
  5. Akathisia- urge to keep moving.

For this reason it is extremely important to be able to properly recognize the various different syndromes of pain in Parkinson’s patients and the best way to do this is getting a detail history- that’s where YOU COME IN!!!

As I mentioned previously untreated pain can lead to devastating consequences in all aspects of life. Know that all types can exist in the same patient throughout the disease course. Thus, identifying quality, location, triggering mechanisms can be extremely useful for your physician to provide the best treatment possible. Keeping a diary helps both you and your physician(s) to get started in the right direction. Once the source of pain is identified proper treatment can be initiated. Many times the pain can be managed successfully by your MDS/ neurologist. However, there may be times that other specialist might need to get involved. Subsequently, treating pain in Parkinson’s patients takes a multidisciplinary team or approach in which you must partner with your

1) MDS/neurologists– he or she MUST always be the quarterback or gate keeper to ensure best outcome!!! They not only know you best but first can determine if pain is related to PD either central (primary pain –i.e. Symptom of PD like tremors or stiffness etc.); or pain due to medication “Too Much” causing akathisias- or severe inner restlessness or “too little” causing dystonias or musculoskeletal pain at large joint due to rigidity, contractures and lack of flexibility and mobility.

2) PT/ OT– they will help you do stretching exercises, Range of motion exercises to prevent contracture and increase flexibility and mobility.

3) Pain specialists– this I would defer as last resort once exhausted all other venues of treatment to obtain narcotics or opiods because even a small dose CAN & WILL make PD symptoms worse in terms of cognition, constipation, sedation, depression, memory, prone to cause hallucinations, increase risk of falls, and may also directly interact with the PD medications negatively. However, they have a place if for instance you have nerve root pain and tried medications and not sure if want to do surgery or not a surgical candidate, nerve block may just do the trick and since its effect is localized will not interfere with other PD medications.

4) PCP/primary care doctor– some times because Parkinson’s is usually not the only disease most of us have, other medical illnesses like diabetes, arthritis, and gout could be the cause of your pain. Hence, it will be up to your primary doctor to do the appropriate laboratory to check for these underlying causes. In the case of cramps, these can be due to electrolyte abnormalities, medication withdrawal (dopamine agonists), or be a harbinger that you are developing neuropathies. So both neurologists and PCP have to be aware of these!!!

5) Psychiatrist/psychologists– because depression colors our perception and pain can makes depressed starting a vicious cycle sometimes we need a little help breaking this cycle to be able to rid the pain and the depression! There for psychotherapy may be beneficial.

6) Neurosurgeon – if there is a herniated disc- with clear dermatome distribution with WEAKNESS and pain unresponsive to other treatment modalities! ( MUST HAVE WEAKNESS otherwise having surgery for pain is a 50/50 shot of getting better and if you don’t get better you might get worst!! If no WEAKNESS involved suggest Botox injections or/and DBS electrical stimulation for pain –have been shown to have great response in my personal experience in my years of practice. A baclofen pump also works well for those that have a lot of pain due to spasticity. (ALL of these procedures MUST be done by someone with LOTS of experience for OPTIMAL results!!!) All of these latter procedures can be done by various specialists depending where you live so trust your neurologists, ask lots of questions always and go with someone with lots of experience!

According to 2 recent studies, there seems to be a consensus that PD patients should delay or avoid back surgery or fusion because of higher risk for “failed back syndrome.” The reason for this is believed to be natural PD symptomatology like poor posture and brittle bones ( although these studies were very small less than 30 patients each, I think that the message is valid but requires further study).

As someone who has undergone two similar back surgeries performed by the same physician one few years prior to my PD diagnosis and one as recent as last year as well as having treated countless patients with back pain including many of whom had PD; I tell you that the recovery is much different and harder with PD. It took me several months to recuperate and get strength back the second time around. My patients and I required increased dosages of dopa in order to overcome weakness!

While the procedure had been exactly same and actually much longer surgery the first time I was back to work within a week! Not a lot of data is available on the subject, but the rare article does allude to the fact that there is an increase in likelihood of compression of nerve roots as well as bulging and herniated discs simply by way of mechanical extrusion from asymmetrical stiffness, bad posturing and abnormal ambulation. I believe this is true for me and most of us with PD that suddenly end up with herniated discs without history of trauma, injury nor hard labor.  (I had a pristine back and neck and  literally had a spontaneous herniated disc doing routine activities without trauma as was the case for my first disc injury – lifting a patient)!!!

Thus, before you submit to surgery make sure it is ABSOLUTELY necessary and have exhausted all other resources!

7) Orthopedist – if there are fractures causing pain, or joint dislocations, or carpal tunnel.

First thing to rule out is pain due to Parkinson’s disease central pain. Or due to wearing off either one requires PD medication adjustment. The main stay of treatment of all syndromes after identifying cause is medication. The types of medications we use for pain include muscle relaxants (have to watch for a couple of them which may interfere with the PD meds and vice versa). Antiinflamatories, also work well. The ones I like best in this class are topical e.g. ketorolac -Toradol ( Flector patch, or your pharmacist can make a compound of topical toradol and topical anesthetics e.g. patches (lidoderm 5% patches, or lidocaine topical lidocaine intment).

Other treatments include antidepressants, anti anxiety, anticonvulsants, while opioids should be taken as last resort. What I have found is that especially with acute pain that is radicular in nature or due to fracture it is best to treat with strong medications as soon as pain comes on to prevent from becoming chronic and/or central then can go back to other treatments above. Usually something like a hydocodone will do if you treat as soon as pain starts. Worse disservice you can do to yourself is waiting until the pain is unbearable before you seek medical attention. This will make your pain much more difficult to control. YOU DON’T have to be STOIC!

Besides medications along with a team approach, other alternative therapeutic modalities reported to be effective anecdotally are:

Massage therapy & Acupuncture – again first discuss with your MDS make sure this is appropriate and find someone that is reputable in the community. Down side is that these services are usually not covered by insurance and thus are an out of pocket expense!

Next time you have pain, you will know exactly what to do and rather than suffering or enduring you can take charge and confront head on.

References:

http://www.pdf.org  topics on pain

Surgical outcome of lumbar fusion surgery in patients with Parkinson disease. J spinal Disord Tech. 2012-PubMed-NCBI

Spinal Surgery inpatients with Parkinson’s disease: experience with the challenges posed by sagittal imbalance and the Parkinson’s spine. Eur Spine J. Oct. 2010; 19(10);1785-1794.

Parkinson’s Disease Sufferers-  spinal -foundation.org

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

Categories: chronic illness, parkinson's disease, parkinsons health and beauty tipsTags: , , , , , , , , , ,

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