How would you treat Parkinson's

How Doctors Targeted Pain in Parkinson's Disease

Stuttgart. The prevalence of pain among Parkinson's patients is difficult to estimate and is given in publications as 40-80 percent, as Professor Wolfgang Jost from the Parkinson Clinic Ortenau, Wolfach reported on the occasion of this year's neurology congress. In a 2017 study, 95 percent of those questioned stated pain, and almost a quarter had the diagnosis “pain syndrome” or “pain disorder”.

Chronic pain lasting more than six months was reported by 61 percent, pain attacks in the last four weeks 79 percent, of which a good half occurred several times a day. An accumulation at a certain time of the day was not found. About half of Parkinson's patients felt that their daily life was clearly or severely affected by the pain.

The assessment and differentiation of pain in Parkinson's is difficult. On the one hand, patients often withhold pain from their neurologist, even if it is frequent and severe, explained Jost. Because they do not associate the pain with their illness, especially since the back is often affected. The first point of contact for complaints is therefore the orthopedic surgeon. About two thirds of the patients believed that Parkinson's disease increased the pain, among other things, because of poor posture, but not that it was the cause of the pain, said Jost. In addition, doctors and patients usually focused more on motor symptoms.

No suitable pain scales

Another obstacle to pain assessment is that there are no suitable pain scales. The King’s PD Pain Scale has established itself, but is not suitable for pain therapists, since the seven domains overlap and the questions are unspecific. "The King’s PD Pain Scale is the best we have, but not good enough for the Parkinsonologist," Jost clarified. The classification of Parkinson's pain according to Ford is similarly problematic. It differentiates between musculoskeletal, arthritic / articular and neuropathic pain, pain due to dystonia, pain due to rigor / bradykinesia, discomfort with akathisia, restless legs syndrome and central pain, which is only useful to a limited extent .

95% of Parkinson's patients reported pain in a study. Chronic pain was 61 percent.

About half of Parkinson's patients take analgesics, according to Jost, while three quarters receive some kind of pain therapy, including physiotherapy, massages and rehabilitation measures. The effect often lasts for less than four weeks. As Jost explains in a recent review, both nociceptive and neuropathic pain occur in the context of Parkinson's disease, some are associated with Parkinson's disease, others are not (Expert Opin Pharmacother 2019; 15: 1847-54). Therefore, the diagnosis requires a differentiated anamnesis and exact examination. A lot would be used in therapy - from dopaminergics to opioids, NSAIDs / metamizole, anticonvulsants and antidepressants to cannabinoids, but mostly without a relevant database.

Expert conclusion

The pain therapy is ultimately unspecific and does not take into account the special requirements of Parkinson's patients. According to a meta-analysis from 2018, safinamide is the most effective, followed by cannabinoids and opioids, whereas dopamine agonists were not very effective (Neuroepidemiology 2018; 51: 190-206). Jost pointed out that it was unclear how much of the effect of safinamide was due to the motor skills and not the pain.

The expert's conclusion is therefore: In step 1, the dopamine agonists should be optimally adjusted, then physiotherapy should be prescribed. If this is not enough, analgesics should be used, opioids only as the last step.