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

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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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.

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