Musculoskeletal pain in Parkinson's disease

Musculoskeletal pain in Parkinson's disease (PD)

• most common PD pain symptom is pain arising from joints, muscles, and the axial skeleton (1)
• can present as a prodromal symptom
• been shown that severity of pain is significantly correlated with the severity of motor complications of PD (2)
• prevalence of musculoskeletal pain ranges from 40% to 75% in those patients with PD experiencing pain (2)
  • musculoskeletal problems are more common in patients with PD than in elderly without PD
• PD disease process causes:
  • camptocormia (abnormal forward trunk flexion) and
  • Pisa syndrome (abnormal lateral trunk flexion) accompanied by muscular rigidity

• leads to abnormal posture and stress on ligaments, facet joints, and soft tissue resulting in pain

• presentation of musculoskeletal pain presentation is similar to patients without PD; however, subtle postural abnormalities need to be explored clinically as this pain is not amenable to traditional pain relief medication and needs physiotherapeutic interventions and rehabilitation (1)
• most frequent presentations are
  • low back pain
    • prevalence of low back pain is 50% higher in PD than age-matched controls (1)
    • risk factors for lower back pain include older age, higher depression score, and PD-related factors, including rigidity and poor posture (2)
    • stated that patients with PD that have lower back pain have longer disease durations and higher pain intensities, compared to those without pain (2)
  • shoulder pain
    • unilateral musculoskeletal pain, especially in shoulder arm distribution, is highly specific of PD and may predate rigidity and bradykinesia (1)
  • arthralgias
    • patients with PD that have co-morbid osteoarthritis reported specific pain characteristics (2)
      • more likely to have paraesthesia- and akathisia-related pain, and less likely to have aching pain, compared to patients with PD without osteoarthritis
  • general muscle aches and cramps
• non-pharmacological management:
  • multidisciplinary approach to care involving specialist nurses, physiotherapy, occupational therapy, and social prescribing is highly recommended
  • a balanced diet
    • can address pains related to constipation, decreased bone density, and low mood
    • food affects levodopa absorption resulting in steady state levels of dopamine, which may alleviate some symptoms
  • early recognition and treatment of depression also helps in pain modulation
  • exercise therapy, involving correct posture and muscle strengthening, improves musculoskeletal pain and quality of life
  • acupuncture and alternative therapies such as mindfulness or meditation may be of value in motivated patients
• specific management (1):
  • suggested first-line therapy options include:
    • non-steroidal anti inflammatory drugs (NSAIDs)
    • physiotherapy
    • occupational therapy
  • suggested second-line therapy options include:
    • low-dose opioids
    • tricyclic antidepressants

Reference:

• Khan AZ et al. Pain syndromes in Parkinson’s disease: an update for general practice. BJGP 2024; 74 (739): 90-92.
• Tai YC, Lin CH. An overview of pain in Parkinson's disease. Clin Park Relat Disord. 2019 Nov 28;2:1-8.