Pain is a common but overlooked problem in Parkinson’s disease.
Pain is an often overlooked non-motor symptom of Parkinson’s disease (PD). 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. (Please feel free to suggest a topic for future blog posts.)
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.
Painful symptoms of Parkinson’s 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 there’s 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.
Types of pain in Parkinson’s
One review classified the types of PD pain as follows:
- musculoskeletal, in which the pain results from problems with the muscles , bones or joints
- dystonic, which is due to abnormal muscle contractions caused by PD or the medications used to treat it
- radicular pain or nerve pain
- central pain, which is poorly understood and thought to be due to abnormalities in the brain itself
This category includes common causes of pain in the general population such as arthritic pains and muscle aches. Although these pains are not due to PD per se, they can be worsened by PD. For example, rigidity, or stiffness of muscles that is a key motor symptom of PD, can worsen muscular pains. Certain PD gaits, such as one in which the torso tilts to the side, may put more stress on particular joints, increasing arthritic pain.
Dystonia, or abnormal posturing, can accompany PD and can be very painful. Some typical patterns of dystonia include curling of the toes or turning inward of the foot.
Dystonia may appear when there is a decrease in brain dopamine levels, which could occur first thing in the morning before taking medication or when a dose of medication is wearing off. If this is the pattern that is noted, various strategies can be implemented to decrease OFF time. Alternatively, dystonia can also be a side effect of treatment with levodopa.
Radicular pain (Nerve pain)
Radicular pain is generally a shooting pain or an electrical sensation that travels along the route of a nerve. This can be due to common conditions such as a herniated disc or arthritis in the lower spine or neck. These types of conditions can be painful in those without PD, but in someone with PD, who walks with a stoop at the shoulders or a bend at the waist, the pain may be worse.
Central pain is a pain syndrome caused by damage or dysfunction of the brain or spinal cord. A wide range of conditions (aside from PD) can be responsible for this type of pain, including stroke and multiple sclerosis. The symptoms can be highly variable between people and can include sensations such as burning, aching, or stabbing. The pain can involve a limb, the abdomen or the genitals and is usually described as deep in origin. It is often exacerbated by a light touch or cold temperature. Because it can be unclear what the origin of the pain is, people with this type of pain often undergo a large number of medical tests to exclude other causes of pain, only to eventually be told that the pain is central pain. Central pain is the hardest type of pain to treat.
Sometimes it can be helpful to keep a pain diary which can give you a sense of when the pain happens and what makes it worse or better. This type of information can be helpful to your doctor when trying to diagnose and treat your pain.
Pain Management in Parkinson’s Disease
Treat OFF time
As discussed above, dystonic pain that occurs when medications have worn off, should be treated by adjusting medications to minimize OFF time. You can learn about ways to treat OFF time by watching one of our webinars on the topic.
Occasionally, non-dystonic pains can also be an OFF phenomenon, and can improve with a dose of levodopa. People with PD who have pain in this pattern are said to have “non-motor OFFs”. These patients, in addition to, or instead of, having fluctuations of their motor symptoms in response to PD meds, have fluctuations in non-motor symptoms, which could include pain, depression or anxiety. If pain occurs in this way, it can often be treated by adjusting medications to minimize the OFF time.
Depression is a very common non-motor symptom in PD – with pain and depression closely linked. Depression can contribute to chronic pain and chronic pain can lead to or increase depression.
Sometimes treatment of depression can alleviate an element of the pain, so an evaluation of depression is definitely warranted when trying to figure out how to treat chronic pain in PD.
Exercises that strengthen the core and encourage upright posture can be very beneficial for certain pains of PD. Working with a physical therapist is essential if the goal is to treat pain, because he/she can design specific exercises for reduce and not exacerbate the pain. Speak with your doctor about a referral to physical therapy (preferably one who is trained in treating people with PD) or call the APDA National Rehabilitation Resource Center, which serves as a central resource for information about PD-related rehabilitation and exercise.
Massage therapy and acupuncture are two complementary treatments that are often used for pain. There have been small studies investigating the use of massage therapy and acupuncture for motor symptoms of PD, but more studies are necessary to definitely determine if they truly help with PD pain.
NSAIDs (non-steroidal anti-inflammatory drugs) which include medications such as ibuprofen and naproxen, as well as acetaminophen can be very beneficial for pain in PD, as they are for the general population. These medications do not typically have neurologic side effects, so they are well tolerated in people with PD. They can have other side effects though, so as always, discuss all medications that you are taking, including over the counter medications, with your doctor.
A number of medications are available for treatment of nerve-related pains and can be tried for some of the pain syndromes of PD. These include gabapentin, duloxetine, and pregabalin. These medications are not taken as needed, that is, just when the pain occurs, but rather every day. They are typically well-tolerated, but may have neurologic side effects such as sleepiness.
Lidoderm patches are embedded with a topical anesthetic and can be helpful for localized pains. Opioids are usually not good options for pain in people with PD. In addition to the development of tolerance to these medications, they can also cause constipation and confusion, which can be non-motor symptoms for people with PD even without additional medications.
Medical marijuana is often used by people with PD for treatment of pain, although not yet proven scientifically to be beneficial in this use. There has not been a clinical trial studying whether medical marijuana works for pain in PD, so we don’t yet know if it is helpful, but a clinical trial is planned to address this question and we hope to have more definitive information in the near future.
There are also a number of procedures that can help with pain. For example, epidural injections are often performed for lower back pain. You can ask your neurologist whether there are any procedures that may be considered to help your particular pain and if so, for a referral to a specialist who performs that procedure.
Tips and Takeaways
- Before assuming that a new pain is related to PD, you may need a medical workup of possible other causes
- Pain can be a common non-motor symptom of PD that can have profound effects on your quality of life.
- There are various types of pains in people with PD. Some are unique to PD. Others are pains that are common in the general population, but may be exacerbated in those with PD.
- There are options to treat your pain, so be sure to discuss your pain with your neurologist.