Pain management in patients with Parkinson's disease: challenges and solutions

Orjan Skogar,1,2 Johan Lokk2 1Academy for Health and Care (FUTURUM), Region Jönköping County, Jönköping, 2Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden Abstract: This review focuses on the diagnosis and management of Parkinson-related pain which is one of the more frequently reported nonmotor symptoms in Parkinson’s disease (PD), which is the second most common neurodegenerative disease after Alzheimer’s disease. Pain is ranked high by patients as a troublesome symptom in all stages of the disease. In early-stage PD, pain is rated as the most bothersome symptom. Knowledge of the correct diagnosis of pain origin and possible methods of treatments for pain relief in PD is of great importance. The symptoms have a great negative impact on health-related quality of life. Separating PD-related pain from pain of other origins is an important challenge and can be characterized as “many syndromes under the same umbrella”. Among the different forms of PD-related pain, musculoskeletal pain is the most common form, accounting for 40%–90% of reported pain in PD patients. Augmentation by pathophysiological pathways other than those secondary to rigidity, tremor, or any of the other motor manifestations of the disease seems most probable. In PD, the basal ganglia process somatosensory information differently, and increased subjective pain sensitivity with lower electrical and heat-pain thresholds has been reported in PD patients. The mechanism is assumed to be diminished activity of the descending inhibitory control system of the basal ganglia. PD pain, like many of the nonmotor symptoms, remains underdiagnosed and, thus, poorly managed. A systematic collection of patient descriptions of type, quality, and duration of pain is, therefore, of utmost importance. Recent studies have validated new and more specific and dedicated pain scales for PD-related symptoms. Symptomatic treatments based on clinical pain classification include not only pharmacological but also nonpharmacological methods and, to some degree, invasive approaches. In the clinic, pharmacological and nonpharmacological interventions can be effective to varying degrees – as single therapies or in combination – and should be employed, because no therapeutic strategies have been validated to date for managing PD pain. Multimodal approaches should always be considered, dopamine replacement therapies should be adjusted, and analgesics and/or antidepressants should be considered, including the use of different forms of complementary therapies. Keywords: basal ganglia, complementary therapies, nonmotor symptoms, pain, Parkinson’s disease, quality of lif

Distribution of non-motor symptoms in idiopathic Parkinson’s disease and secondary Parkinsonism

Orjan Skogar,1,2 Mats Nilsson1,3 1FUTURUM, Academy for Health and Care, Region Jönköping County, Jönköping, Sweden; 2Institution of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; 3Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Background: Non-motor symptoms (NMS) are frequent in patients with idiopathic Parkinson’s disease (IPD). Clinical expressions, postulated pathophysiological mechanisms, and responsiveness to antiparkinson medication represent differences between IPD and secondary Parkinsonism (SP).Objective: To evaluate NMS expressions in IPD, SP, and a matched control group.Methods: The accepted criteria for IPD and SP were controlled for the participants who were consecutively recruited at two outdoor patient clinics. The Well-Being Map™ was used as the evaluation instrument. These were completed by the participants before their visit. The controls consisted of non-Parkinsonian individuals who were matched by age and gender.Results: A total of 185 participants participated in the study, IPD/SP/controls; n=73/53 and 59, respectively. The mean age was 74 years, and the median duration of disease was 6/3 years. Differences were shown between the combined IPD/SP groups and the controls. Limited differences between the IPD and SP groups could be demonstrated. Symptoms such as pain, decreased taste, as well as sleep and bladder disturbances were more frequent in the IPD group. When more than minor problems with moving were reported, disturbances in sleep and digestion were also noted to a large extent.Conclusion: Despite differences in the pathophysiological mechanisms between IPD and SP, the study showed only minor differences in the expression of NMS. IPD and SP reported statistically more significant problems in all items compared to the controls. Sleeping problems were strongly associated with symptoms from the gastrointestinal tract, but sleep was only affected by longer disease duration to a minor extent. Motor symptoms, such as morning stiffness, were common in all three groups. Neurodegenerative diseases might have more complex expressions in common than what we have known before and it is certainly not a part of normal aging. Keywords: idiopathic Parkinson’s disease, motor symptoms, non-motor symptoms, secondary Parkinsonism, well-being map, Health related Quality of Lif