Treatment of Pain in PD
Because Parkinson’s remains an incurable illness, the goal of any treatment intervention must be quality of life and pain has a significant impact.
In fact accurate treatment will help reduce some of the consequences of pain, particularly decreased mobility, depression and anxiety all of which negatively affect quality of life.
Unfortunately pain in Parkinson’s disease is largely undertreated and once identified, difficult to manage. As with any other aspect of this disease, patient proactivity and involvement are integral to a successful approach to managing this symptom.
Psychosocial factors can influence the experience of pain to a great degree. Stress of any nature from sources either related to the Parkinson’s or of a completely different nature such as financial or occupational burden, or relationship issues can definitely heighten the perception of pain. Therefore reducing stress by learning ways to cope with the stressors can be highly beneficial.
Treating any co-morbidities or other conditions that aggravate pain such as a mood disorder (depression or anxiety) or sleep disturbance for example, will also help to reduce pain. In other words, if mood is improved and sleep is adequate, pain is less likely to be as disabling.
Physical modalities also play an important role and are interventions that can be implemented by patients themselves. Examples include hot packs (heating pad, microwaveable bags etc.) which are good at relieving muscle tension and spasm. Applying them to the area of pain for 30 minutes at a time, helps. Cold packs on the other hand, are important for acute injury or tendonitis (which sometimes occurs with repetitive dyskinesia).
Exercise and improved overall fitness is important in general but both active stretching on your own and passive stretching with a trainer or partner are not only helpful for maintaining flexibility but help stretch muscles that otherwise are shortened or in spasm.
Other health professionals can assist in pain relief and their interventions are an important part of the non-pharmacologic approach to treating pain.
Physiotherapy may help in reducing pain resulting from the motor symptoms of PD such as rigidity and postural abnormalities. Massage therapy can also make a positive impact by physically manipulating tense muscles and trigger points. Other complementary health practices such as acupuncture have anecdotally, provided some degree of pain relief as well.
If following these interventions, sufficient relief is not felt then medical intervention may be necessary. In the case of musculoskeletal pain, there may be dramatic improvement with effective treatment of parkinsonian motor symptoms - in other words getting on the correct dosage and scheduling of Parkinson’s medications. Sometimes pain will fluctuate with motor symptoms and the medication schedule needs to be modified. If pain is more bothersome in the “off” state for example, maximizing “on” time through various medication changes such as increasing the frequency of L-dopa or using a longer acting agent such as a dopamine agonist or controlled release L-dopa, may be warranted. If the symptoms of PD are well controlled, then it follows that pain that stems from the motor aspects of the disease will improve as well.
Unfortunately however, initiating or modifying dopaminergic therapy does not improve pain for the majority of patients reflecting the complexity of this problem. In these instances additional medications may be necessary and it may take ongoing monitoring and many different treatment trials (or even referral to a pain specialist) before adequate relief is reached.
In the case of musculoskeletal or neuropathic pain, response to analgesic agents is variable and unpredictable. Acetaminophen can be of some benefit but in most cases a combination of medications are required including those that normally treat depression or epilepsy. Opioids may also be considered.
When pain is related to dystonia, the addition of amantadine or a muscle relaxant or benzodiazepine may work. For those with significant dystonia or spasm in a single muscle group, injection of botulinum toxin remains a viable option.
Because Parkinson’s remains an incurable illness, the goal of any treatment intervention must be quality of life and pain has a significant impact. In fact accurate treatment will help reduce some of the consequences of pain, particularly decreased mobility, depression and anxiety all of which negatively affect quality of life.