The Pages section of GPnotebook comprises more than 30,000 concise, interlinked clinical reference articles, each focused on a specific primary care topic.
Parkinson’s disease is a condition I find intimidating. There are many challenges. The initial diagnosis can be tricky to make, especially if it presents gradually or atypically. Medication regimens are complex and managed mostly by secondary care. This is all in the context of a diagnosis which can be devastating for patients and their families. It brings upon your patients a huge physical and psychological burden, and they need support from healthcare structures.
As a GP, it’s easy to feel disempowered when faced with patients presenting with issues relating to Parkinson’s disease.
A recent update to the GPnotebook page on pain in Parkinson’s disease gave me the reality check I needed on this topic. It reminded me that no matter how complex the situation, we can always provide support to our patients by offering common-sense pointers on the practical management of typical issues such as pain.
The updated page discusses the important issue of musculoskeletal pain in people living with Parkinson’s disease. It highlights that this kind of pain is a very common symptom in Parkinson’s disease, being encountered more often in people with this condition than in our older population without it. It also shows that it is an area where we can make a difference.
Musculoskeletal pain can present as a prodromal symptom for Parkinson’s disease. In established Parkinson’s disease, the severity of pain is often correlated with the severity of motor complications.
Some interesting terms describe the mechanisms behind the pain, including:
These elements lead to abnormal posture and increased stress on ligaments, facet joints and soft tissue. This pathway leads to the musculoskeletal pain that our patients with Parkinson’s disease often live with.
So, what are people likely to report in Parkinson’s disease? Or what specific symptoms should we ask about?
Lower back pain is common, and its prevalence is 50% higher than in people who do not have Parkinson’s disease. Shoulder pain is another common presentation, and it is often unilateral and can predate rigidity and bradykinesia.
Of course, there may also be comorbid osteoarthritis. Interestingly, the typical symptoms reported in people with Parkinson’s disease and osteoarthritis are slightly different from those with just the former. For instance, the group with both are more likely to experience paraesthesia- and akathisia-related pain, and less likely to experience aching pain, compared with people who have only Parkinson’s disease.
Musculoskeletal pain in Parkinson’s disease can be complex, and, in some cases, traditional pain relief will not be effective as treatment. Non-pharmacological management is crucial, and involving the multidisciplinary team in the community can really add value, not least through the inclusion of physiotherapy and occupational therapy colleagues. Exercise therapy, covering correct posture and muscle strengthening, improves musculoskeletal pain and quality of life.
Diet is often not the first thing you think of when managing pain, but it also plays a role. Maintaining a balanced diet is important in Parkinson’s disease in general, in order to avoid constipation and the abdominal pain that can occur with this and to aid the stable absorption of medication to reduce stiffness (a contributor to pain).
Early recognition and treatment of depression also helps in pain modulation. Acupuncture and alternative therapies such as those based on mindfulness or meditation may be of value in some patients.
When using painkillers, there is nothing earth-shattering to say. Suggested first-line therapy options include non-steroidal anti-inflammatory drugs if safe and appropriate for the individual patient. Second-line therapy options include low-dose opioids and tricyclic antidepressants, again with a need to weigh up risks and benefits.
People with Parkinson’s disease can also have pain related to neuropathy or from central pain syndrome. The GPnotebook pages for these conditions here and here are really worth a look.
Also, a general overview of Parkinson’s disease can be found here, for anyone interested in brushing up on this topic.
For me, researching this month’s email reminded me that the recognition of common symptoms such as pain in primary care can be really important for people with complex conditions, and it certainly made me feel more empowered in dealing with people presenting with Parkinson’s disease.
I hope you enjoyed this month’s update, and I look forward to writing for you again next month.
Since 2001, GPnotebook has been a "go-to" clinical reference source for busy primary care professionals seeking quick answers to clinical queries
Written by practising GPs, GPnotebook comprises more than 30,000 pages of clinical reference material, with each article focused on a specific primary care topic
Information is organised into short, easy-to-read articles – quick enough to use during consultations. Hundreds of updates every month
As well as the written reference material, we have a growing library of video and podcast content, along with educational modules and quizzes to support learning and personal development