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

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: Parkinson’s disease; basal ganglia; complementary therapies; nonmotor symptoms; pain; quality of life.

Figure 1

The pathophysiological basis of sensory disturbances in PD, the so-called “pain matrix” with information from different loci, processed in the BG. Notes: Reprinted from Journal of the Neurological Sciences; 289(1–2); Juri C, Rodriguez-Oroz M, Obeso JA; The pathophysiological basis of sensory disturbances in Parkinson’s disease; 60–65; Copyright 2010, with permission from Elsevier. The blue dashed line indicates proposed modulator function from STN. Lewy bodies are observed in the vagal nucleuus and locus coeruleus during early stages of PD. These areas contribute to the so-called “pain matrix”. Sensory information of the integrational sensory information in the basal ganglia. Afferent sensory information; different regions of somatosensory cortices converge into striatum where it would interfere with information processing. Abbreviations: PD, Parkinson’s disease; BG, basal ganglia; GPe, globus pallidus externa, GPi, globus pallidus interna; STN, subthalamic nucleus.

Figure 2

The Pain-O-Meter (Swedish Version).

Figure 3

A simplified scheme of pain evaluation and origin in PD. Abbreviation: PD, Parkinson’s disease.

Figure 4

Visualization of chronic pain localization for males and females. Note: Adapted from Skogar O, Fall PA, Hallgren G, et al. Parkinson’s disease patients’ subjective descriptions of characteristics of chronic pain, sleeping patterns and health-related quality of life. Neuropsychiatr Dis Treat. 2012;8:435–442. © 2012 Skogar et al, publisher and licensee Dove Medical Press Ltd.