Pain due to akathisia and/or dystonia in Parkinson's disease

Pain due to akathisia and/or dystonia in Parkinson's disease (PD)

• seen as an offshoot of the OFF phenomenon (phenomenon where there is re-emergence of PD symptoms when the plasma levodopa level decreases) (1)
• akathisia (is defined as an inability to remain still)
  • is a treatment-related phenomenon that is not painful but has highly displeasing sensations manifesting as subjective restlessness and an urge to move
• dystonic pain in PD
  • because of forceful contraction of a muscle group or body area
    • are various clinical features of foot dystonia (2)
      • ranging from simple forms, such as inversion or hallux extension
        • to complex forms
          • combinations of inversion, plantar and toe flexion, intra-rotation, and dorsal and hallux extension
      • typically occur in the morning, before the first dose of levodopa, or even during medicated periods
      • foot and toe dystonia are very painful and cause walking difficulties
  • develops in approximately one-third of patients with PD that receive long-term levodopa treatments (2)
  • when pain is associated with worsening motor disability or with fluctuation-dependent dystonia, usually, the first step is to adjust the dose of anti-parkinsonian medication (2)
  • usually, but not always, seen in levodopa-treated patients
    • in them its identification is important as it may respond to optimisation of conventional anti-Parkinsonian treatment (1)
• general non-pharmacological management of pain in PD:
  • 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 of akathisia (1):
  • suggested first-line therapy options include:
    • dopamine agonists
  • suggested second-line therapy options include:
    • intestinal levodopa gel

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.