Initiation Propagation And Maintenance Of The Pain State
While we do not know the underlying mechanisms that drive PD singular, persistent pain singular, nor persistent pain in PD, bench and bedside research investigative efforts have partially defined some of the factors important in the initiation, propagation and maintenance of each. Continued forward and back translational preclinical and clinical research will provide comprehensive disease pathology insight and guide towards a mechanism based therapeutic approach to facilitate analgesic target identification. Psychophysical testing in humans, with its promise to link animal and clinical pain studies, is essential to fully understand the mechanisms that contribute to the development of persistent pain.
Since A Back Injury In 1985 John Has Experienced Multiple Types Of Pain Some Of Which Have Been Triggered By His Parkinson’s He Was Diagnosed With The Condition In 2016
Ive been experiencing varying degrees of pain since injuring my back, which caused me to have lower-back pain, which continues to this day. Since then, I have also developed pain in other parts of my body due to Parkinsons, including my hands, ribs, upper back and shoulder.
The pain in my ribs is deep, aching and constant, and I get internal tremors in this area. However, the pains in my legs are sharp, intermittent and become very rigid, especially in my calves.
When I walk, the pain can get so bad that I end up having to stop and rest. On really bad days, I use a wheelchair. When Im in a lot of pain, it affects my Parkinsons symptoms even more, and also my spatial awareness, that I tend to lose my balance and fall or freeze.
I was referred to a pain specialist…who enrolled me on an 8-week pain management course led by a Parkinson’s-trained physiotherapist. Now I do an hour of gentle movements and stretching every morning.
I cant stand for long enough to wash and have a shave, or to wash the dishes, so I use a perching stool. I can no longer carry out my hobby of canoeing to the same degree. While I use to be able to do it all day, I’m now lucky if I can do it for an hour.
I was referred to a pain specialist, who prescribed me medication, and advised on workable changes to my lifestyle and diet. They also enrolled me on an 8-week pain management course led by a Parkinson’s-trained physiotherapist. Now I do an hour of gentle movements and stretching every morning.
Why Pain Occurs In Parkinsons Disease
Parkinsons is a brain disease that is caused by the death of cells responsible for dopamine production. Dopamine is a chemical messenger that plays an important role in body movement. It is mainly concentrated in the substantia nigra part of the brain. When its production ceased in the brain, the body experience abnormal movement .
In addition to the substantia nigra, dopamine can also be found in other regions of the brain like thalamus, basal ganglia, insula, and anterior cingulate cortex. These regions are typically associated with pain perception. The presence of dopamine in these areas suggests that, in addition to its main role in the movement, dopamine may also involve in the modulation of pain sensation within the brain .
In fact, recent research shows that a low level of dopamine in some of these regions contribute to develop pain in the body. This evidence strongly suggests that apart from motor symptoms, a low level of dopamine also causes pain. And this could be the likely reason why people with Parkinsons feel pain in their body .
But most clinicians think that Parkinsons disease symptoms are the actual cause of pain. The pain is directly linked to the intensity of symptoms, the more strong the symptom the more pain will be felt .
For example, rigidity is one of the major symptoms in Parkinsons patients. Those patients who have high rigidity are tended to experience more pain than those who have less.
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Examples Of Pain Scales In Pd
This is a self-administered pain assessment tool developed for the purpose of improving pain assessment and management in acute and chronic pain patients, not exclusively for PD pain. It is a hard, white, plastic tool. Two methods for assessing pain are located on the Pain-O-Meter . The first is a 10-cm VAS with a moveable marker that patients use to rate their pain. The second is a list of 15 sensory and eleven affective WDSs. Each WDS is assigned an intensity value that can be as low as 1 or as high as 5 .
|Durationa of disease, 5 years/> 5 years||Pain before/after PD diagnosis||Durationb of pain/day, 10 h/> 10 h||VAS,c5 cm/> 5 cm||Pain expressions by participants|
Notes: POM results for PD and chronic pain patients. Data from Skogar et al.
Abbreviations: PD, Parkinsons disease h, hours VAS, visual analog scale RLS, restless legs syndrome POM, Pain-O-Meter.
Kings PD Pain Scale
Pathophysiological Pathways Of Pain In Pd
The origin of pain in PD remains poorly understood. At times, it appears as dystonia when the dopaminergic effects wear off. The pathophysiological mechanisms behind this phenomenon are most probable by which dopamine, in the network with other monoamines such as noradrenaline and 5-hydroxytryptamine , interacts through inhibitory and excitatory pathways. Abnormalities in descending pathways affect central pain processing. In addition, clinically registered neuropathic pain and other muscular pain sensations are described by PD patients. This has led to the exploration of pathways other than those secondary to rigidity, tremor, or any other motor manifestations of the disease, with abnormal nociception processing in PD patients suffering from pain as the most likely suspect. The basal ganglia process somatosensory information in different ways, and increased subjective pain sensitivity with lower electrical and heat pain thresholds has been reported in PD patients. This abnormal processing also comprises PD-related disorders such as multiple system atrophy, which exhibits almost the same prevalence of pain as PD.
The pathophysiological basis of sensory disturbances in PD, the so-called pain matrix with information from different loci, processed in the BG.
Abbreviations: PD, Parkinsons disease BG, basal ganglia GPe, globus pallidus externa, GPi, globus pallidus interna STN, subthalamic nucleus.
Static And Dynamic Psychophysical Paradigms
So-called static psychosocial paradigms refer to a range of quantitative sensory testing protocols, which were recently standardised and defined by the German research network on neuropathic pain . In addition to sensory detection thresholds the DFNS protocol involves pain thresholds to thermal and mechanical stimuli. If QST responses are incongruous to normative reference values the dysfunction may be located anywhere along the neural axis, from peripheral nerve fibres,, to the spinal cord and cortical areas. However the value of QST to distinguish central and peripheral mechanisms is limited. Nociceptive withdrawal reflex thresholds offer a measure of central pain processing, specifically spinal nociceptive facilitation.
Pain Is A Common But Overlooked Problem In Parkinsons Disease
Pain is an often overlooked non-motor symptom of Parkinsons disease . Studies show that between 40-80% of people with PD report pain, which is likely why it is often suggested as a topic for this blog.
One of the reasons why the topic of pain and PD is difficult to address is that it is sometimes tough to discern whether a particular pain is due to PD or not. Chronic pain is such a common symptom among the general population, and people with PD are not immune to common problems as well. However, there are aspects of PD that may exacerbate the pain experienced from a common problem. In addition, there are particular types of pain that may be unique to people with PD.
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Q What Is The Role Of Depression In The Pain Experience In Pd
Dr. Fleisher: Depression is one of the most overlooked symptoms of PD, and it can affect over 30% of people with the disease at some point in their illness.5 I think there is a misconception that depression results from an adjustment disorder following diagnosis. While that may be partially true, patients with PD have alterations in various neurotransmittersincluding serotonin and norepinephrine in addition to dopaminethat predispose them to depression.6,7
Depression is the primary factor related to quality of life in PD and is an independent risk factor for medication nonadherence. A physician could prescribe the most comprehensive regimen to control Parkinsons symptoms, including pain, but if depression symptoms are not being addressed simultaneously, the likelihood that that person is going to take that regimen is pretty minimal.
Given the link between depression and chronic pain, patients who are depressed should be screened for chronic pain and vice versa. In my practice, we screen every patient with the Unified Parkinsons Disease rating scale , which has both a patient-reported subjective component that includes questions about depression, pain, and altered sensation, as well as an objective component that includes a physical examination and questions about potential medication adverse effects . The patient fills out the subjective component every single time they come to the office.
How Is Pain Diagnosed Assessed And Treated
Diagnosing and treating pain in people with Parkinsons can be difficult and often, common ways of reducing pain, such taking painkillers or doing regular, gentle exercise may not help.
Usually, your doctor or Parkinsons nurse specialist will be able to help you to manage the more common types of pain, such as shoulder pain and headaches. Certain other types of pain, however, such as pain caused by involuntary movements or burning mouth, may need the help of your Parkinsons specialist.
Completing a Kings Parkinsons Disease Pain Questionnaire and showing it to your heath-care professional will help them to understand the pain you are suffering from1. Completing the 24-hour Hauser2 diary, a home diary designed to assess your motor symptoms, over the same period of time, would further help your doctor or Parkinsons nurse to better understand the pain you are experiencing and to treat it more quickly.
To ensure Parkinsons pain is assessed and diagnosed efficiently, a specific scale has been designed. Kings Parkinsons Pain Scale 1 is a validated scale which covers the common types of Parkinsons related pain. Your Parkinsons specialist might use this scale to help understand the type of Parkinsons pain you have even better and assess what needs to be done to help you further.
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All Up A Multidisciplinary Team Approach For Pain Management May Be Necessary In Addition To Your Movement Disorder Specialist Providers May Include Physical Or Occupational Therapists Psychiatrists And Even Pain Management Experts Each Of These Practitioners Targets A Different Aspect Of The Pain
Exercise to Relieve your Pain
Many different types of exercise can be beneficial for people with Parkinsons disease , including non-contact boxing, tai chi, dancing and cycling, as some examples. If you have limited mobility, you can try chair yoga or other seated exercises. Whichever exercise you choose, make sure it is something safe and enjoyable so that you can stick with it.
Its important to pace yourself and know your personal limitations. If during or after exercise you experience extreme pain you should look at modifying your routine and choose a less intensive exercise. Even the simplest exercise, including walking your dog or just puttering around the house or garden, can help alleviate symptoms of pain.
If you need help or advise consult with a physical or occupational therapist to help design a personalised program for you. Learn more about exercise and Parkinsons.
Non-pharmacological pain treatments
Complementary therapies are treatments used alongside conventional medicine. They take a more holistic approach than conventional medicine, aiming to treat the whole person including mind, body and spirit, rather than just the symptoms. These include massage therapy, mindfulness and meditation techniques, acupuncture, and heat or cold application. These may be used on their own or in combination with medication.
A Bottle Neck To Neurological Health
I have noticed that a lot of people with Parkinsons Disease, and other neurological disorders too, such as Alzheimers, suffer with severe neck pain and/or stiff, rigid necks. In terms of neurological problems, our necks can be a pinch point – a constricted passageway or tunnel, through which all the superhighways between our brain and the rest of our nervous system and organs, and from there, out into the far reaches of our fingers and toes, must pass. All of our utilities, the two-way electrical wirings, the broadband and telegraph wires of the nervous system, the water and air supplies, the chemical pipelines providing nutrients and the sewer pipes taking away the excreta of the brain, must pass through this narrow gap. This is no ordinary tunnel: to keep these utility supplies open and running, it was designed to keep on moving itself and in truly extraordinary ways of flexible motions.
Even slight damage or stiffening up of the neck can cause constrictions or interruptions of these important electrical and chemical flows. For oxygen and nutrients that enter through the mouth or nose, it is double jeopardy, as they have to pass through the bottle-neck twice, down into the lungs or to the gut, and back up again to get the brain. The neck is therefore a primary attention site for progressive symptom reduction strategies. In this article, we look at aspects of the neck and consider what we can do to improve our lot.
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Painful Symptoms Of Parkinsons Disease
Pain can sometimes be an early symptom of PD. For example, a person may complain of a painful shoulder and be diagnosed with an orthopedic condition such as a frozen shoulder, only to develop a rest tremor on that side at a later point. The painful shoulder was in fact not a frozen shoulder after all, but rather pain due to the rigidity of PD. Now of course, sometimes a frozen shoulder is really just a frozen shoulder, so theres no need to jump to conclusions when you are experiencing pain. Not every ache and pain is a sign of PD, but it is important for you to educate yourself, be aware of the possible connections, and be proactive about seeking medical attention for any notable pain you are experiencing.
If you have PD and develop pain, it is important to first bring this to the attention of your doctor. The pain may be related to your PD, or the pain may be due to a common problem such as arthritis which is exacerbated by your PD. However, in some cases, it may be a symptom of a more serious medical problem. So do not assume that the pain is related to your PD before getting an appropriate medical workup.
Fluctuations Of Pain Experiences In Pd
Patterns of NMS fluctuations are heterogeneous and complex. Psychic NMS seem to fluctuate more frequently and severely than nonpsychic symptoms. A recent study of ten frequent NMS in advanced PD using VAS rating scales in motor-defined on- and off-states, as well as self-ratings at home, confirmed previous suspicions that increased pain in off-states and pain fluctuations correlate with a low health-related quality of life. Pain as NMS was more frequent in the off-state more precisely, it was three to four times more common during the off-state than during the on-state.
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Pain Shows Up As Parkinson’s Sets In
Study Shows Pain Is Felt at Onset of Parkinson’s Disease
New research shows that another thing to look for as Parkinson’s takes hold is pain.
The study, led by Giovanni Defazio, MD, of the University of Bari, shows that people with Parkinson’s have more pain than those who are disease-free.
Researchers found that the pain seems to show up with the onset of the disease or shortly thereafter.
The research team looked at 402 patients who had Parkinson’s disease, comparing them to 317 people who did not have the disorder.
The groups were similar in ages and the proportion of men and women.
However, more Parkinson’s participants had depression and medical conditions associated with pain symptoms, such as diabetes and herniated discs.
Taking into account age, sex, depression, and other medical conditions associated with pain, 70% of the Parkinson’s patients said they experienced pain lasting at least three months, compared with 63% of the comparison group.
Among the Parkinson’s patients, 17% had dystonia. Dystonic pain was more commonly located in the leg, foot, neck, or shoulders.
When it came to pain that was nondystonic, rates were similar between Parkinson patients and the comparison group.
The average age for the onset of Parkinson’s disease was 60.
What Is The Outlook For Persons With Parkinsons Disease
Although there is no cure or absolute evidence of ways to prevent Parkinsons disease, scientists are working hard to learn more about the disease and find innovative ways to better manage it, prevent it from progressing and ultimately curing it.
Currently, you and your healthcare teams efforts are focused on medical management of your symptoms along with general health and lifestyle improvement recommendations . By identifying individual symptoms and adjusting the course of action based on changes in symptoms, most people with Parkinsons disease can live fulfilling lives.
The future is hopeful. Some of the research underway includes:
- Using stem cells to produce new neurons, which would produce dopamine.
- Producing a dopamine-producing enzyme that is delivered to a gene in the brain that controls movement.
- Using a naturally occurring human protein glial cell-line derived neurotrophic factor, GDNF to protect dopamine-releasing nerve cells.
Many other investigations are underway too. Much has been learned, much progress has been made and additional discoveries are likely to come.
Pain In Parkinsons Disease
Parkinsons patients suffer from the same pain other people have, often amplified by the motor dysfunction, but they also have additional pain problems unique to PD. Lower back pain and back of he neck pain are most common. Strengthening exercises or stretching may be helpful. Identifying the cause of the pain is essential in treating the pain. Treatments include physical therapy, medications, and alternative therapies like Reiki, acupuncture and massage.