Back problems in Parkinson’s disease: an underestimated problem

Turning when using a smartphone in persons with and without neurologic conditions: an observational study (Preprint)

BACKGROUND

Turning during walking is a relevant and common everyday movement and it depends on a correct top-down intersegmental coordination. This could be reduced in several conditions (en bloc turning), and an altered turning kinematics has been linked to increased risk of falls. Smartphone use has been associated with poorer balance and gait; however, its effect on turning-while-walking has not been investigated yet. This study explores turning intersegmental coordination during smartphone use in different age groups and neurologic conditions.

OBJECTIVE

This study aims to evaluate the effect of smartphone use on turning behavior in healthy individuals of different ages and those with various neurological diseases.

METHODS

Younger (aged 18-60 years) and older (aged >60 years) healthy individuals and those with Parkinson disease, multiple sclerosis, subacute stroke (<4 weeks), or lower-back pain performed turning-while-walking alone (single task [ST]) and while performing 2 different cognitive tasks of increasing complexity (dual task [DT]). The mobility task consisted of walking up and down a 5-m walkway at self-selected speed, thus including 180° turns. Cognitive tasks consisted of a simple reaction time test (simple DT [SDT]) and a numerical Stroop test (complex DT [CDT]). General (turn duration and the number of steps while turning), segmental (peak angular velocity), and intersegmental turning parameters (intersegmental turning onset latency and maximum intersegmental angle) were extracted for head, sternum, and pelvis using a motion capture system and a turning detection algorithm.

RESULTS

In total, 121 participants were enrolled. All participants, irrespective of age and neurologic disease, showed a reduced intersegmental turning onset latency and a reduced maximum intersegmental angle of both pelvis and sternum relative to head, thus indicating an en bloc turning behavior when using a smartphone. With regard to change from the ST to turning when using a smartphone, participants with Parkinson disease reduced their peak angular velocity the most, which was significantly different from lower-back pain relative to the head (P<.01). Participants with stroke showed en bloc turning already without smartphone use.

CONCLUSIONS

Smartphone use during turning-while-walking may lead to en bloc turning and thus increase fall risk across age and neurologic disease groups. This behavior is probably particularly dangerous for those groups with the most pronounced changes in turning parameters during smartphone use and the highest fall risk, such as individuals with Parkinson disease. Moreover, the experimental paradigm presented here might be useful in differentiating individuals with lower-back pain without and those with early or prodromal Parkinson disease. In individuals with subacute stroke, en bloc turning could represent a compensative strategy to overcome the newly occurring mobility deficit. Considering the ubiquitous smartphone use in daily life, this study should stimulate future studies in the area of fall risk and neurological and orthopedic diseases.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022998; https://drks.de/search/en/trial/DRKS00022998.

Bipolar Lumbar Radiofrequency Medial Branch Neurotomy in a Patient with Deep Brain Stimulation Implant

Chronic axial lower back pain is one of the most common conditions that patients seek medical attention for in pain practices. About 15 to 40% of axial lower back pain is due to facet-mediated pain. Diagnostic blocks of the medial branch reliably identify the facet joint as the pain generator and offer a prognostic factor for response to radiofrequency neurotomy of the identified facet joints resulting in profound pain relief. However, deep brain stimulation implants have been considered a contraindication for neurotomy. We present an illustrative case of a patient with deep brain stimulation system treated with bipolar medial branch neurotomy using a two-needle technique.

Spinal Surgery after Bilateral Subthalamic Stimulation for Patients with Parkinson's Disease: A Retrospective Outcome Analysis of Pain and Functional Control

Parkinson’s disease (PD) patients often suffer from spinal diseases requiring surgeries, although the risk of complications is high. There are few reports on outcomes after spinal surgery for PD patients with deep brain stimulation (DBS). The objective of this study was to explore the data on spinal surgery for PD patients with precedent DBS. We evaluated 24 consecutive PD patients with 28 spinal surgeries from 2007 to 2017 who received at least a 2-year follow-up. The characteristics and outcomes of PD patients after spinal surgery were compared to those of 156 non-PD patients with degenerative spinal diseases treated in 2013–2017. Then, the characteristics, outcomes, and spinal alignment of PD patients receiving DBS were analyzed in degenerative spinal/lumbar diseases. The mean age at the time of spinal surgery was 68 years. The Hoehn and Yahr score regarding PD was stage 1 for 8 patients, stage 2 for 2 patients, stage 3 for 8 patients, stage 4 for 10 patients, and stage 5 for 0 patient. The median preoperative L-DOPA equivalent daily dose was 410 mg. Thirteen patients (46%) received precedent subthalamic nucleus (STN) DBS. Lumbar lesions with pain were common, and operation and anesthesia times were long in PD patients. Pain and functional improvement of PD patients persisted for 2 years after surgery with a higher complication rate than for non-PD patients. PD patients with STN DBS maintained better lumbar lordosis for 2 years after spinal surgery. STN DBS significantly maintained spinal alignment with subsequent pain and functional amelioration 2 years after surgery. The outcomes of spinal surgery for PD patients might be favorably affected by thorough treatment for PD including DBS.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

Multimodal treatment including lumbar facet joint denervation for severe low back pain in patients with neuromuscular disorders

BACKGROUND

Severe low back pain (LBP) is an occasional complaint in patients with neuromuscular disorders (NMDs). Accurate diagnosis and treatment are required to manage LBP; however, the precise pathophysiology differs for each patient. This study aimed to evaluate the efficacy of lumbar facet joint denervation (FJD) and adjunctive modalities in the treatment of LBP in patients with NMD-associated kyphoscoliosis.

METHODS

A total of 16 patients (22 sites) with NMD (bilateral, n = 6; unilateral, n = 10) and LBP treated with lumbar FJD were evaluated. The patients were divided into two groups: those treated with FJD alone (group 1) and those treated with multimodal treatment, including FJD along with radiofrequency ablation for sacroiliac joint pain, piriform muscle block, botulinum toxin injection into the paraspinal muscles, spinal cord stimulation, or any of their combinations (group 2). All patients were followed up for 48 weeks postoperatively. The two groups were compared with respect to the duration required for improvements in LBP by more than 50% (numerical rating scale ≤ 5).

RESULTS

There was no significant difference between the groups regarding the age, duration since the onset of Parkinson's syndrome, and radiographic analysis. The effective period of improved pain was greater in group 2 than in group 1 (30.7 vs. 8.4 weeks, P < 0.01).

CONCLUSIONS

Multimodal treatment including FJD is safe and relatively effective in patients with NMD-associated kyphoscoliosis. Hence, it is a potential substitute for conventional spinal fixation surgery, which has a higher risk of complications.

Low back pain in Parkinson's disease: A cross-sectional study of its prevalence, and implications on functional capacity and quality of life

OBJECTIVE

The aim of this study was to estimate the prevalence of low back pain (LBP) in patients with Parkinson's disease (PD) and its impact on functional capacity and quality of life.

METHODS

Patients with idiopathic PD answered a questionnaire and were submitted to a clinical and functional assessment. Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr Scale, Beck Depression Inventory (BDI), McGill Pain Questionnaire (McGill), Roland Morris Disability Questionnaire (RMDQ), 39-item Parkinson's Disease Questionnaire (PDQ-39) were used. In addition, the ability to contract transversus abdominis (TrA) was assessed.

RESULTS

One hundred and fifteen patients answered the questionnaire, and 95 (82.6 %) reported painful symptoms. Of these, 67 (58.3 %) had chronic LBP, and approximately 40 % patients reported its onset before diagnosis of PD. Higher scores in pain intensity, depressive symptoms and UPDRS II and III, more advanced stages of PD, and absence of TrA contraction determined poor functional limitation induced by LBP. However, pain intensity (McGill), severity of PD symptoms (UPDRS III) and absence of TrA contraction were identified as predictive factors for functional limitation and explained 66.1 % of the variance in the RMDQ. Pain intensity and LBP-related disability caused negative impact on the quality of life.

CONCLUSION

LBP is common in patients with PD and it causes disability and poor quality of life. Pain intensity, UPDRS III and absence of TrA contraction were the most significant predictive factors for disability assessed by the RMDQ.

Low Back Pain--Related Disability in Parkinson Disease: Impact on Functional Mobility, Physical Activity, and Quality of Life

BACKGROUND

People with Parkinson disease (PD) frequently experience low back pain (LBP), yet the impact of LBP on functional mobility, physical activity, and quality of life (QOL) has not been described in PD.

OBJECTIVE

The objectives of this study were to describe body positions and functional activities associated with LBP and to determine the relationships between LBP-related disability and PD motor sign severity, physical activity level, and QOL.

DESIGN

The study was a cross-sectional study.

METHODS

Thirty participants with idiopathic PD (mean age = 64.6 years [SD = 10.3]; 15 women) completed the Revised Oswestry Disability Questionnaire (RODQ), a measure of LBP-related disability. PD motor symptom severity was measured using the Movement Disorder Society-Unified Parkinson Disease Rating Scale Part III (MDS-UPRDS III). The Physical Activity Scale for the Elderly (PASE) was used to measure self-reported physical activity. The Parkinson Disease Questionnaire-39 (PDQ-39) was used to measure QOL. Descriptive statistics were used to characterize LBP intensity and LBP-related disability. Spearman correlations were used to determine relationships between the RODQ and the MDS-UPDRS III, PASE, and PDQ-39.

RESULTS

LBP was reported to be of at least moderate intensity by 63.3% of participants. LBP most frequently impaired standing, sleeping, lifting, and walking. The RODQ was significantly related to the MDS-UPDRS III (r = 0.38), PASE (r = -0.37), PDQ-39 summary index (r = 0.55), PDQ-39 mobility subdomain (r = 0.54), and PDQ-39 bodily pain subdomain (r = 0.44).

LIMITATIONS

Limitations included a small sample of people with mild to moderate PD severity, the fact that RODQ is a less frequently used measure of LBP-related disability, and the lack of a non-PD control group.

CONCLUSIONS

LBP affected walking, sleeping, standing, and lifting in this small sample of people with mild to moderate PD. Greater LBP-related disability was associated with greater motor sign severity, lower physical activity level, and lower QOL in people with PD.

Toward more focused multimodal and multidisciplinary approaches for pain management in Parkinson's disease

In Parkinson’s disease (PD), pain represents a significant issue in terms of prevalence, clinical features, and treatment. Painful manifestations not strictly related to the disease are often amplified by the motor dysfunction. On the other hand, typical pain problems may specifically concern this vulnerable population. In turn, pain may have a deep impact on patients’ health-related quality of life. However, pain treatment in PD remains an unmet need as only about half of patients with pain use analgesics and pain is often managed by simply increasing doses of PD medications. In this complex scenario, pain treatments should follow multimodal approaches through a careful combination of pharmacological agents with non-pharmacological strategies, depending on the type of pain and the clinical context. A multidisciplinary approach involving medical specialists from different disciplines could be a winning strategy to address the issue. This work is aimed to provide practical suggestions useful for different types of clinicians and care professionals for pain management in this vulnerable population.

Spinal Fusion in Parkinson's Disease Patients: A Propensity Score-Matched Analysis With Minimum 2-Year Surveillance

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To compare outcomes and complication rates between patients with and without Parkinson's disease (PD) patients undergoing surgery for adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

There is limited literature evaluating the impact of PD on long-term outcomes after thoracolumbar fusion surgery for ASD.

METHODS

Patients admitted from 2009 to 2011 with diagnoses of ASD who underwent any thoracolumbar fusion procedure with a minimum 2-year follow-up surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. A 1:1 propensity score-match by age, Deyo score, and number of fused vertebral levels was conducted before comparing surgical outcomes of patients with ASD with and without PD. Univariate analysis compared demographics, complications, and subsequent revision. Multivariate binary stepwise logistic regression models identified independent predictors of these outcomes (covariates: age, sex, Deyo Index score, and PD diagnosis).

RESULTS

A total of 576 propensity score-matched patients were identified (PD: n = 288; no-PD: n = 288), with a mean age of 69.7 years (PD) and 70.2 years (no-PD). Each cohort had comparable distributions of age, sex, race, insurance provider, Deyo score, and number of levels fused (all P > 0.05). Patients with PD incurred higher total charges across ASD surgery-related visits ($187,807 vs. $126,610, P < 0.001), yet rates of medical complications (35.8% PD vs. 34.0% no-PD, P = 0.662) and revision surgery (12.2% vs. 10.8%, P > 0.05) were comparable. Postoperative mortality rates were comparable between PD and no-PD cohorts (2.8% vs. 1.4%, P = 0.243). Logistic regression identified nine-level or higher spinal fusion as a significant predictor for an increase in total complications (odds ratio = 5.64); PD was not associated with increased odds of any adverse outcomes.

CONCLUSION

Aside from higher hospital charges incurred, patients with PD experienced comparable overall complication and revision rates to a propensity score-matched patient cohort without PD from the general population undergoing thoracolumbar fusion surgery. These results can support management of concerns and postoperative expectations in this patient cohort.

LEVEL OF EVIDENCE

3.

What If Low Back Pain Is the Most Prevalent Parkinsonism in the World?

Low back pain (LBP) has a point prevalence of nearly 10% and ranks highest in global disease burden for years lived with disability; Parkinson’s disease (PD) ranks in the top 100 most disabling health conditions for years lost and years lived with disability (1). Recent evidence suggests that people with chronic, recurrent LBP exhibit many postural impairments reminiscent of a neurological postural disorder such as PD. We compare and contrast postural impairments associated with LBP and PD in order to inform treatment strategies for both conditions. The literature suggests that both LBP and PD associate with impaired proprioceptive function, sensory orientation during standing balance, anticipatory postural adjustments, automatic postural responses, and striatal-cortical function. Although postural impairments are similar in nature for LBP and PD, the postural impairments with LBP appear more specific to the trunk than for PD. Likewise, although both health conditions associate with altered striatal-cortical function, the nature of the altered neural structure or function differ for PD and LBP. Due to the high prevalence of LBP associated with PD, focused treatment of LBP in people with PD may render benefit to their postural impairments and disabilities. In addition, LBP would likely benefit from being considered more than just a musculoskeletal injury; as such, clinicians should consider including approaches that address impairments of postural motor control.

Management of Spinal Conditions in Patients With Parkinson Disease

Parkinson disease (PD) is increasingly prevalent in the aging population. Spine disorders in patients with PD may be degenerative in nature or may arise secondary to motor effects related to the parkinsonian disease process. Physicians providing care for patients with PD and spine pathologies must be aware of several factors that affect treatment, including the patterns of spinal deformity, complex drug interactions, and PD-associated osteoporosis. Following spine surgery, complication rates are higher in patients with PD than in those without the disease. Literature on spine surgery in this patient population is limited by small cohort size, the heterogeneous patient population, and variable treatment protocols. However, most studies emphasize the need for preoperative optimization of motor control with appropriate medications and deep brain stimulation, as well as consultation with a movement disorder specialist. Future studies must control for confounding variables, such as the type of surgery and PD severity, to improve understanding of spinal pathology and treatment options in this patient population.

Characteristics of spinopelvic alignment in Parkinson's disease: Comparison with adult spinal deformity

PURPOSE

The characteristics and pathogenesis of spinopelvic alignment in Parkinsons's disease (PD) patients-including differences compared to non-PD subjects and their relationships with the severity of PD-have not been clarified. The aim of this study was to investigate the characteristics of spinopelvic alignment in patients with PD.

METHODS

Forty-eight PD patients complaining of chronic low back pain were included (PD group). The PD condition, determined using the Hoehn and Yahr (H&Y) stage and Unified Parkinson Disease Rating Scale (UPDRS) score; radiographic spinopelvic alignment; lumbar range of motion (ROM); and low back pain-related quality of life assessments were evaluated. Fifty age- and sex-matched patients with adult spinal deformities were included as controls (ASD group).

RESULTS

The spinopelvic alignments of the PD/ASD groups demonstrated sagittal vertical axes of 120.9/106.3 mm and pelvic incidences of 49.7/52.9°, with no significant differences. Conversely, there were significant differences in the thoracic kyphosis (TK; 27.6/16.7°), lumbar lordosis (-22.7/-7.9°), and pelvic tilt (25.3/34.4°) (all, p < 0.05). With regard to correlations with the PD condition, the H&Y stage demonstrated significant correlations with the sagittal vertical axis, thoracolumbar kyphosis, and lumbar ROM (all, p < 0.05), and the UPDRS score tended to correlate with the TK and thoracolumbar kyphosis (both, p < 0.01).

CONCLUSION

Characteristic spinal conditions in PD exist, with progressed PD condition causing stooped posture with increased thoracic or thoracolumbar kyphosis and decreased lumbar ROM; moreover, global sagittal malalignment progresses without sufficient compensatory mechanisms such as loss of TK and pelvic retroversion.

Transforaminal Percutaneous Endoscopic Discectomy in Parkinson Disease: Preliminary Results and Short Review of the Literature

Objective

To study the effectiveness of Transforaminal Percutaneous Endoscopic Discectomy (TPED) for lumbar disc herniation in patients with Parkinson disease (PD).

Methods

Fifteen patients diagnosed with PD and lumbar disc hernia were recruited to the study. All patients underwent TPED. Mean age was 61.27±6 years, with 8 male (53.3%) and 7 female patients (46.7%). Level of operation was L3-4 (33.3%), L4-5 (33.3%) and L5-S1 (33.3%). Visual analogue scale (VAS) for leg pain and Oswestry Disabillity Index (ODI) for back pain, as well as the Medical Outcomes Study Questionnaire Short-Form 36 Health Survey (SF-36) for health-related quality of life (HRQoL) were assessed right before surgery and at 6 weeks, 3, 6, and 12 months after surgery.

Results

VAS and ODI showed significant (p<0.005) reduction one year after TPED, with a percentage improvement of 83.9% and 79.4%, respectively. Similarly, all aspects of quality of life (SF-36) were significantly (p<0.005) improved 1 year after the procedure. Bodily pain and role physical demonstrated the highest increase followed by role emotional, physical function, social function, vitality, mental health, and general health. Beneficial impact of TPED on clinical outcome and HRQoL was independent of gender and operated level.

Conclusion

TPED is effective in reducing lower limb symptoms and low back pain in patients with lumbar disc hernia, suffering from PD. Positive effect of endoscopy is, also, evident in HRQoL of those patients one year after the procedure.

[Lumbar back pain in patients with Parkinson's disease]

BACKGROUND

Lumbar back pain is a frequent symptom in patients with advanced Parkinson's disease. We examined the effect of modification of the dopaminergic medication, x-ray-controlled lumbar spine injections and analgesics combined with physiotherapy.

METHODS

The data from 50 patients with Parkinson's disease and lumbar back pain were retrospectively analyzed. A structured L-dopa test was performed with all patients, whereby the pain intensity and mobility were monitored before and after the administration of L-dopa. Dopaminergic medication was adjusted in patients who reported either a reduction in pain intensity (> 20%) and/or an improvement of measured mobility and X-ray controlled lumbar spine injections were conducted in patients who reported persistent pain. Analgesics were introduced or dosages were raised in patients who had already received lumbar spine injections and continued to report pain. All patients participated in a daily physiotherapy program.

RESULTS

In the L-dopa test an improvement of mobility could be demonstrated in 40 patients and reduced pain intensity in 21 patients. In 37 patients with a positive L-dopa test the dopaminergic medication was adjusted. In 12 of these patients (24%) a decrease of pain intensity could be observed. Due to persisting back pain in 30 patients lumbar spine injections were conducted. Of these patients 17 (34%) had pain improvement. In 20 patients analgesics were applied and induced pain relief in 15 patients (30%). Overall 44 patients (88%) had an improvement in pain.

DISCUSSION

Even in cases of severe lumbar spine pathology adjustment of dopaminergic medication should be tested in all patients with Parkinson's disease and lumbar back pain. In patients with persistent pain facet joint injections as well as analgesics may be helpful and should be tested according to the predominant pain characteristics.

Characteristics and exacerbating factors of chronic low back pain in Parkinson's disease

BACKGROUND

The aim of this study was to determine the exacerbating factors of chronic low back pain (LBP) and strategic points against LBP in patients with Parkinson's disease (PD).

METHODS

Forty-four consecutive PD patients complaining of LBP were included. Clinical characteristics of PD and LBP, spinal musculoskeletal condition, and clinical health status were evaluated.

RESULTS

Patient age at PD and LBP onset was contiguous, and LBP time period was mainly described as constant or upon waking up. Exacerbating factors of LBP included modified Hoehn and Yahr stage and motor complications of PD, such as the wearing-off phenomenon and dyskinesia. Bone quality demonstrated osteopenia due to elevated bone resorption, with vitamins K and D insufficiencies. Spinal alignment demonstrated an increased sagittal vertical axis (120.2 ± 65.4 mm) with decreased lumbar lordosis (-24.0 ± 20.6°) and lumbar range of motion (28.7 ± 10.2°), which were significantly related to severity of LBP and quality of life assessments.

CONCLUSIONS

This study demonstrated that exacerbating factors of LBP include stage of motor function, motor complications of PD and stooped posture with decreased lumbar lordosis and range of lumbar movement. Therefore, control of PD, including motor complications, active treatment for osteoporosis and therapeutic exercise, are important for treating chronic LBP in patients with PD.

Deep brain stimulation significantly decreases disability from low back pain in patients with advanced Parkinson's disease

BACKGROUND

Up to 60% of Parkinson's disease (PD) patients suffer from low back pain (LBP) during the course of their disease. How LBP affects daily functional status and how to manage this aspect of PD has not been adequately explored.

METHODS

We examined 16 patients undergoing bilateral subthalamic nucleus deep brain stimulation (STN DBS) who met the inclusion criteria for moderate disability from LBP, as classified by the Oswestry Low Back Pain Disability Index (OLBPD).

RESULTS

Thirteen of 16 patients had attempted additional treatments for LBP, including medical management, massage, chiropractic, epidural steroid injections and/or surgery, with minimal relief. Following DBS, there was a significant improvement in the OLBPD at both the 6-month and 1-year time points (p < 0.02, p < 0.005, respectively). A mean improvement of 31.7% on the OLBPD score was noted. The Visual Analogue Scale (VAS) similarly decreased significantly at 1 year (p = 0.015). There was no correlation between the OLBPD score and other measures, including the Unified Parkinson's Disease Rating Scale (UPDRS), age and other nonmotor symptoms.

CONCLUSION

Given the prevalent yet undertreated disability associated with LBP in PD, these results are novel in that they show that STN DBS has a significant positive effect on disability associated with LBP.

Epidemiology of neurologically disabling disorders

Neurological disorders place a considerable burden upon individuals, their families, and society. Some like stroke are common, while others like amyotrophic lateral sclerosis are much rarer. Some conditions such as multiple sclerosis are reported to vary by latitude, while others such as traumatic brain injury can vary considerably by locality. Depending upon the nature of the lesion, and factors such as time since onset, the consequences to the individual may also vary considerably, not just among different disorders, but within a given disorder. Consequently the patterns of disease incidence, its prevalence, and its consequences are complex and may vary not just because of the condition itself, but also because, for example, case ascertainment may vary from study to study. The cumulative annual incidence of disabling neurological disorders is likely to exceed 1000 per 100000, or 1% of the population. The incidence is characterized by significant variation, which is mediated by genetic, geographical, demographic, and environmental factors. While useful comparisons can be made through standardization techniques, planning for local services should be based upon local epidemiology, whenever available.

Management of pain in Parkinson's disease

Pain is a common symptom in Parkinson's disease (PD) and accounts for substantial morbidity in up to 80 % of patients. Despite contributing to disease-related discomfort and disability, pain in PD frequently goes underacknowledged and undertreated in clinical practice. Although the exact underlying neurophysiology is unclear, there is increasing understanding of the role of the basal ganglia in somatosensory processing, as well as involvement of additional brainstem structures and non-dopaminergic pathways; appreciation of these mechanisms has implications for treatment strategies. Categorizing painful symptoms based on their clinical description into musculoskeletal, dystonic, radicular-peripheral neuropathic and central pain categories provides a useful framework for management. Importantly, these symptoms should be evaluated in relation to motor symptoms and dopaminergic therapy. A multi-disciplinary approach is recommended as follows: physical therapy, liaison with pain management and consultations to rheumatological, orthopaedic and neurosurgical services should be considered.

The benefit of subthalamic deep brain stimulation for pain in Parkinson disease: a 2-year follow-up study

BACKGROUND

Pain is a well-recognized feature of Parkinson disease (PD), which is primarily a motor disorder. In a previous study, we showed that subthalamic deep brain stimulation (STN DBS) improves pain as well as motor symptoms 3 months after surgery in PD patients.

OBJECTIVE

To determine whether there is a long-term beneficial effect of STN DBS on pain in PD.

METHODS

We studied 21 patients with PD who underwent STN DBS. Motor symptoms were assessed using the Unified Parkinson's Disease Rating Scale and Hoehn and Yahr staging. Pain was evaluated by asking patients about the quality and severity of pain in each body part. Evaluations were performed at baseline and at 3 and 24 months after surgery.

RESULTS

At baseline, 18 of the 21 patients (86%) experienced pain. After surgery, most of the pain reported at baseline had improved or disappeared at 3 months and improved further at 24 months. The benefit of STN DBS for pain evaluated at 24 months was comparable to that with medication at baseline. At 24 months, 9 patients (43%) reported new pain that was not present at baseline. Most of the new pain was musculoskeletal in quality. Despite the development of new pain, the mean pain score at follow-up was lower than at baseline.

CONCLUSION

STN DBS improves pain in PD, and this beneficial effect persists, being observed after a prolonged follow-up of 24 months. In addition, in many of the PD patients new, mainly musculoskeletal pain developed on longer follow-up.

Prevalence, classification, and etiology of pain in Parkinson's disease: association between Parkinson's disease and fibromyalgia or chronic widespread pain

Parkinson's disease (PD) is characterized by resting tremor, slow and decreased movement (hypokinesia and akinesia), rigidity, postural instability, problems with gait, and coordination. The prevalence of PD is between 0.1% and 0.3% in the general population and between 1% and 2% in persons 65 years of age or older. Patients with PD are more likely to suffer from pain. Indeed, the chief complaint of patients with severe motor disturbance and severe pain is pain rather than motor disturbance. Fibromyalgia (FM) is defined by widespread pain (pain in the left and right sides of the body, pain above the waist, pain below the waist, and axial skeletal pain) for more than 3 months and the presence of at least 11 of the 18 specified tender points. FM and chronic widespread pain (CWP), which is usually an incomplete form of FM, cause pain in the musculoskeletal region, but their etiologies are unknown. Therefore, it is almost impossible to determine whether or not pain in the musculoskeletal region is in the musculoskeletal origin. We suspect that dysfunction or degeneration of the nerves that control pain, mind, and movement in the brain causes FM, depression, and PD, respectively. When pain in PD is discussed, FM and CWP should be considered because their prevalence is high. Patients with PD may be likely to suffer from FM and CWP; however, the prevalence of FM and CWP in patients with PD has not been reported. Here, we discuss the relationship between PD and FM or CWP.

Pain in Parkinson's disease: Prevalence and characteristics

Parkinson's disease is a chronic, progressive, incurable neurodegenerative disease. As the disease progresses, motor disturbances and non-motor symptoms represent considerable illness burdens. Symptom relief is the goal for the treatment. Pain is frequently observed in patients with Parkinson's disease, but its prevalence, characteristics and associations with Parkinson's disease are poorly documented. These were investigated in 176 home-living PD patients. They underwent a neurological examination and a structured interview for registration of pain characteristics in addition to responding to standardised questionnaires. Pain was reported by 146 (83%) patients. Compared to the general population, the Parkinson's disease patients experienced significantly more pain as measured by SF-36 Bodily Pain Scale. The average pain during the last 24h measured by the Brief Pain Inventory was 2.85. Fifty-three percent of the patients reported one, 24% reported two and 5% reported three pain types. Musculoskeletal pain was reported by 70%, dystonic pain by 40%, radicular-neuropathic pain by 20% and central neuropathic pain by 10%. Thirty-four percent were on analgesic medication. Pain was not associated with age, disease duration or severity of the disease; female gender was the only significant predictor of pain. Pain is frequent and disabling, independent of demographic and clinical variables except for female gender, and is significantly more common in Parkinson's patients compared to the general population. A minority of the Parkinson's disease patients with pain received analgesic medication. The findings call for improved attention to assessment and treatment of pain in the follow-up of Parkinson's disease patients.