dystonia in PD, parkinson's disease

Is numbness in my feet caused by my Parkinson’s disease/dystonia? : By Dr. De Leon

“I have become comfortably numb.” Unknown

On a weekly basis, I get the question can PD cause numbness? Well today, I thought I would tackle this sensitive topic from a different angle than before. hopefully this will help so many of you who like me are  plagued with this problem and are not sure where to turn. Image result for images of radiculopathy

First, let me explain a couple of things. we have learned in the last decade or so that Parkinson’s disease can cause pain and central sensory deficits. this means that the brain does not process sensation normally because these connections pass through the basal ganglia on their way to the thalamus (sensory control center in the brain). This usually manifest in abnormal sensations when touch is involved. Plus, this abnormal basal ganglia dysfunction is the source for what we call “central” pain in PD. This is a burning, searing, excruciating pain that is constant deep in the bone aggravated by touch and follows the normal pathways of the brain – usually unilateral but can become bilateral. But, this does not cause numbness or tingling typically. as you might recall one of my initial symptoms was pain- this central pain. I could not stand anyone to touch my limbs which started on my left side, showering was torture. I felt like the water touching me was pure acid.

However, peripheral sensory deficits like toe, feet, and hand numbness has not been shown to be caused by PD itself. The usual test we use to detect neuropathies  called  NCV (nerve conduction velocity) study are normal in PD. Yet, many of us have been down with severe numbness particularly in our lower extremities.

So, why is this?

Well you are neither alone nor crazy. Well, I think I have a logical explanation for these symptoms from my own experience, living with my Parkinson’s and also having treated many patients in the past who regularly complained of this problem.

The cause is a simple mechanical problem. I have had two herniated discs in the past and know full well the symptoms of radiculopathy – numbness and pain shooting down your leg along with accompanying weakness. Of course, the first time I had numbness in my feet and back pain I immediately thought I was having exacerbation of my injured back. however, I had no pain nor weakness only numbness. I discovered that the usual treatments for back spasm like Lidoderm patches, Nsaid’s (non-steroid anti-inflammatories), wearing a brace did not alleviate this problem completely. However, increasing dose of dopaminergic medication e.g. levodopa stopped symptoms instantaneously as soon as medicine kicked in.  Also, over the years I have noticed that when muscles get very tight i.e. dystonia especially in the neck and arms it can mimic cervical radiculopathy, carpal tunnel syndrome, and ulnar neuropathy. as a matter of fact when I was in residency because I was starting to get dystonia carrying my heavy doctors bag I was erroneously diagnosed and given a splint for carpal tunnel. since it was difficult to carry my bag with the brace the symptoms stopped abruptly.

As far as foot and toe numbness, I know too well the feeling. Although not painful it is extremely uncomfortable and if severe it can lead to falls due to loss of proprioception (not knowing where floor is). The main cause for this as I stated earlier is a mechanical one. as we stiffen rather our backs get rigid it decreases the normal curvature of the spine putting tension in our back muscles which then in turn pull on our spine to maintain posture this stretches the space between the vertebra and compresses the nerves as they exit the foramen. end result, the nerves get stretched and compressed decreasing their function acting as if they were being pinched  permanently. As I sit here writing my back is getting tighter and I begin to feel some discomfort in my feet telling me I have to move about. however, when someone is under-medicated you get the same effect severe rigidity of axial muscles ( neck and back) with loss of normal curvature and subsequently the entire nerve collection known as a plexus gets compressed and stretched causing numbness in feet because these are the biggest fibers- so get affected first. the key is that usually this occurs bilaterally simultaneously and without pain or weakness and gets better quickly after taking medication or realigning spine like laying down supine in a flat surface.

Of  course this is not to say that Parkinson’s patients do not get neuropathies ( progressive nerve ending atrophy) from other common causes like B12 deficiency, diabetes, or vitamin deficiencies, or presenting symptom of cancer.

My recommendation to evaluating this problem and feeling better soon is to maintain diary.

  • When it happens?
  • How long it lasts?
  • Does it follow a pattern close to your medications wearing off?
  • Other symptoms associated with it? like changes in bowel/bladder function, weakness, pain, one sided?
  • Does it improve? or is it constant?
  • Have you had dyskinesia’s/ dystonia involving more commonly neck to cause cervical radiculopathy and myelopathy but will have other symptoms.  (the constant gyration of neck can lead to herniated discs, as well as torticollis – abnormal posture of neck due to involuntary sustained contractions).

Talk to your physician and discuss problem. as they check for metabolic problems ask them to adjust your dose of medication ( up usually) before proceeding with any more invasive or expensive tests because in my experience this will remedy problem if caused by Parkinson’s-indirectly.

Finally, staying active and keeping muscles limber by doing exercises routinely- does not necessarily mean daily but at least couple of times a week, can reduce this problem dramatically. As an aside never start any vigorous exercise program like boxing, or other physical regimen before discussing with your physician especially if having numbness or other symptoms because you can seriously injure yourself.

So next time you have problems with feet being numb do not fret and follow these recommendations as you call your doctor to discuss further. However, if symptoms come on suddenly on one side of the body go to ER asap. This could be a stroke!

@copyrights 2015
all rights reserved by Maria De Leon

Parkinson's Health, Parkinsons disease, parkinsons symptoms, parkinsons treatments

How to Deal with the 6 Common Causes of Leg pain in PD? : By Dr. De Leon

One of the biggest complaints I hear from people in PD support groups is a continuous relentless severe leg pain. Prior to a decade ago, I as all my fellow movement disorder specialist would have not thought leg pain to be a direct precursor of PD or an initial non-motor symptom. My grandmother often complained of pain and deep aches in her calves and in her legs which started before her tremors and shuffling were noticeable. But, I was unaware of the connection at the time and erroneously assumed her pain was neuropathic in nature due to her diabetes but was always somewhat surprised that she continue to complain of this pain on and off throughout her illness despite neuropathic medication. With hind sight what she was experiencing was central pain of PD. I too had severe pain first in one leg then the other which would come on suddenly without warning stopping me in my tracks throughout the day. I was constantly asking my husband to massage my legs just as my grandmother had asked of us time and time again.

So why do we have leg pain in PD and what can we do to relieve the discomfort?

First, some believe that lower limb pain is a specific non-motor phenotype variant of central pain in Parkinson’s disease. I, too, believe this; more importantly it can be one of the very first signs of PD as it was for me. This pain is usually bilateral.

Second, leg pain can also occur secondary to dystonia as an initial symptom or as a consequence of long term levodopa use (most common). When related to levodopa it usually occurs as a wearing off but can also occur at peak dose. In most cases this leg pain is unilateral and has direct correlation to medication intake.  When is due to dystonia pain is more common in early morning. This type of leg pain is usually accompanied by toes curling and foot abnormally posturing. dystonia in feet

Third, musculoskeletal pain due to rigidity, abnormal posturing and lack of mobility affects legs commonly causing pain in the legs, however this pain is usually more pronounced on the more affected side.

Fourth, pain in legs can also be caused by radiculopathy; nerves can become trapped or temporarily pinged in the spine or as they exit the spinal canal due to stiffness/rigidity of the muscles which exert an abnormal lordotic (curvature) of spine. Once again, this type of pain is usually confined to only on one side of the body and is positional meaning it is worst with standing and sitting and relieved by laying down. Pain usually radiates from back or hip down to leg and can also get worst with coughing or straining.

Fifth, pain in legs can also be due to medication effects or withdrawal from certain types of medicines like NEUPRO. In the latter, the pain which can be in both legs is more cramping.

Sixth, Let’s us not forget that we do not live in a vacuum and that just because we have PD does not make us immune to other common diseases such as peripheral vascular disease (PAD). Men are more likely to have this but women are not exempt. Risk factors include diabetes (remember PD may increase this risk), high blood pressure (again some PD meds may increase this risk), heart disease, high cholesterol, smoking, stroke, kidney disease.

The symptoms of this are:

– walking fast or uphill or for long periods to point of hurting immediately when walking

-Feet and legs feel numb at rest and skin is pale and cool to touch

Symptoms are worse with elevating legs and better with dangling over the bed.

Sometimes pain in legs can be a combination of all of the above.

Pain can be the most disability of all PD features interfering with all activities of living. Despite this fact it is often under treated and frequently overlooked. Any pain in PD should be promptly and effectively treated especially that of leg pain before the pain becomes chronic and your brain reorganizes itself completely to be able to handle the pain. I feel terrible because I did not fully understand the phenomena of central pain in PD at the time of caring for my grandmother. Fortunately, with adjustment of her levodopa meds her pain subsided for the most part. As I said before we have come a long way in understanding pain in PD, so there should be no reason why anyone should be subjected to dealing with pain on a daily basis when we have so many treatment options.

TREATMENTS:

Treatments therefore depend on properly identifying the source of pain.

  • If bilateral always assume it is central pain- pain due to PD and treat accordingly. As I mentioned many times before, Azilect works great for this type of pain.
  • Massage therapy works for all types of leg pain-my favorite.
  • If having pain due to dystonia first find out if occurring at end of dose or at peak dose so meds can be adjusted. If medication adjustment don’t work consider DBS. Pain due to dystonia also responds well to Botox, Myobloc, or Dysport injections, baclofen, Dantrolene, and Klonopin work well alone or in combination with other treatment modalities. Physical therapy (PT) can go a long way to alleviating pain of this type.
  •   If having radicular pain try trigger point injections, epidurals, nerve block, surgery, DBS (deep brain stimulator) for pain in the spine, Botox, Lidoderm patches, muscle relaxants, anti-inflammatories and steroids and PT.
  • To avoid and alleviate pain caused by stiff muscles the best treatment is activity in the form of stretching exercises- any number of activities will do such as walking, tai-chi, water aerobics, swimming, dancing, bicycling, yoga; of course if needed can use a Tylenol plus a Motrin or Advil as needed. Sometimes may need to up levodopa if stiffness is persisting or add a centrally acting muscle relaxant like baclofen or Neurontin.
  • To avoid cramps stay well hydrated. Make sure your patches don’t fall off! Eat food high in potassium like avocados, bananas, and strawberries. When cramp hits quick remedy spoonful of mustard with warm water or take some pickle juice.
  • If you have symptoms of PAD or suspect consult your physician immediately this can be a life threatening problem!!