As I have spent the last week or so dealing with one type of pain or another I thought it might be worthy to go over the different types of pain people with Parkinson’s disease can experience and discuss some of the ways we can treat such pains while maintaining a full life.
Living with chronic pain is another ball game entirely than dealing with acute pain. As a person who has experience both and treated many patients over the years with both, I think I have a pretty good understanding of the consequences and common pitfalls we as patients and we as doctors fall trapped to when treating pain.
Chronic pain is one that lasts more than 3 months to 6 months since onset. although, some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Acute pain on the other hand is usually one that lasts less than 30 days. Another popular alternative definition of chronic pain, involving no arbitrarily fixed duration, is “pain that extends beyond the expected period of healing”.[1] Epidemiological studies have found that 10.1% to 55.2% of people in various countries have chronic pain.[2]
We know that living with Parkinson’s disease on a daily basis can be a source of frustration and even lead to depression and feelings of hopelessness, if not treated promptly. Just knowing that there is no end in site can create a sense of hopelessness. So people that have intermittent pain have much better coping skills than those with chronic intractable relentless pain. The one common denominator amongst all of us who live with PD is the fact that we will experience pain at some point in our disease usually many times because there is no one single pain type. in fact most of us experience different types of pain even in a single week just as I have this past week, this is because my pain like that of many is caused both by the illness itself, and medications as well as those caused by normal living (wear & tear if you will). Charcot famous neurologist who suggested name of Dr. James Parkinson be used for pathology and clinical symptoms of what we now call PD, recognized more than a 100 years ago that ‘pain’ was a phenomena of PD.
When I was in practice I loved the medication Vioxx ( before it was taken off the market) and so did my PD patients. This medication seemed to do wonders for the majority of patients with PD independent of the source. I, unfortunately, have not come across another medication which has the same effect. my patients too suffered the consequences of not having this medication available.
So you can have pain caused by the disease:
- musculoskeletal
- central
- radicular
- dystonic
- joint
We now know that pain can be a presenting symptom of disease but the incidence in pain increases as we get older and disease advances. the majority of PD patients report pain as a muscle cramp or tightness in the neck, back, paraspinal muscles and calf muscles. The majority of this pain can be alleviated with anti-parkinsonian medications, at least in the acute phase. however, when it becomes chronic it requires a great deal more effort to break cycle which has sensitized the brain to be hyperactive to even the smallest pain.
Pain etiology: (3)
- PD itself:
- tremors
- abnormal posture
- akathesia
- dyskinesia
- dystonia
- falls/trauma
- motor fluctuation
2. medications:
- increase risk of cancer- prostate, melanoma, breast, benign brain tumors
- increase risk of osteoporosis – increasing risk of fractures
- increase migraines/headaches
3.common diseases: which may worsen or change as we age- also may be indirectly exacerbated by PD or PD meds.
- Diabetic neuropathies
- migraines
- herpetic neuralgia- PD patients have increased risk
Therefore, for pain etiology brought on by disease as in #1- the treatment is managing and adjusting dopamine medications including treatment with DBS and ancillary services such as physical, occupational therapy as well as joining in exercises programs but must have doctors approval prior to starting any programs to avoid further damage or exacerbation of symptoms. Botox, muscle relaxants, spine stimulators, baclofen pump, Lidoderm patches, and other muscle relaxant/anti-inflammatories patches, as well as anti- inflammatory medications like ketorolac (Toradol) can play an important role in maintaining patients pain free. The use of prophylactic medications may also play a role in this group but not as much as in the other two. the key is to ALWAYS seek treatment by your MDS and a neurologist. They will then refer you if you need certain procedures or treatments which they themselves cannot perform.
There is no need for narcotic use in most pain situations due to PD unless it has become chronic and ALL other modalities have been exhausted. I don’t mean morphine or Demerol but rather Vicodin, Tylenol #3 etc. Narcotics work great for acute pain due to herniated disc, fractures, cancer pain, or acute radicular pain- this means only a short amount of time until problem is fixed or it becomes chronic because there is no other treatment modality and by then prophylactic medications need to be instituted such as antidepressants and anti-seizure meds (Keppra,Neurontin, Lyrica, Topamax,Tegretol, Lamictal). this will prevent brain from becoming sensitized and will also require much lower doses of narcotics. We don’t want narcotics in PD patients because the potential for exacerbating PD symptoms as well as increasing likelihood of confusion/disorientation and possibly triggering psychosis.
For category two: if medications like Stalevo are causing headaches switch meds; if unable to do so then back to what I described above. monitor for risk of cancer; monitor and institute prophylactic measures for osteoporosis prevention- monitoring vitamin D levels, taking replacement as needed, get sun at least 3 times a week for 30 minutes. Exercise to strengthen bones which will also improve mobility which will decrease likelihood of pain in axial muscles. get regular bone density scans.
For category three: treat diabetic neuropathies with anti seizure meds or antidepressants, take b1 (thiamine) daily, monitor thyroid, and B12 levels which can also cause neuropathies and monitor blood sugars (hga1c- better predictor) since there may be an increase in insulin resistance due to effects of dopamine.
If you are an elderly person and had chicken pox maybe at higher risk of herpetic neuralgia (shingles) should talk to doctor about getting vaccine.
As for me and all my pains which have to do with spine tumors and chronic migraines treatment of choice is botox which I plan on getting in next few days! meantime taking prophylactic meds along with anti-inflammatories (nsaid’s like Mobic, Celebrex, arthrotec,motrin, toradol or steroids) and muscle relaxants ( such as flexeril, tizanidine, Relafen, robaxin, klonopin, baclofen, dantrolene) to ease pain.
Finally, the best way to deal with chronic pain is getting a good nights rest! (at least 8 hours) and listening to your body when it is tired and stressed- make sure you plan ahead some down time each day at least 15-30 minutes. This for me is the best way to deal and avoid pain. Pain starts usually when I don’t sleep well and I am so busy I don’t allote time for myself. This includes time for inner quietness…meditation / praying . When you feel pain coming on – lay down in quiet dark cool place and calm down your breathing and your heart rate …with practice you can achieve this easily.
also distract yourself with activities that will bring joy like spending time with kids/ grandkids/friends but don’t overdue. Other activities which can bring joy and relaxation are painting/coloring /listening to music. Don’t forget to hydrate, eat a balanced meal and exercise at least 3 times a week – this goes a long way in decreasing and warding off pain. Each time I deviate from my routine which includes above pain starts to pop up! Something to think about I your daily life – what triggers your pain? Stress? Lack of sleep?
Go ahead and prioritize time for your yourself – self love goes – includes spiritual well being ( join a bible group) along way towards maintaining health and happiness.
Sources:
- Turk, D.C.; Okifuji, A. (2001). “Pain terms and taxonomies”. In Loeser, D.; Butler, S. H.; Chapman, J.J.; Turk, D. C. Bonica’s Management of Pain (3rd ed.). Lippincott Williams & Wilkins. pp. 18–25. ISBN 0-683-30462-3.
- Harstall C, Ospina M. How Prevalent Is Chronic Pain? June 2003 volume XI issue2 Pain Clinical Updates, International Association for the Study of Pain. pages=1–4 [1]
3. Broetz, et al., 2007; Bunting-Perry et al., 2010; Carr et al., 2003; Carroll et al., 2004; Ford, 1998; Loher, et al., 2002; Stacy et al., 2005; Wielinski et al., 2005
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