Pain Correlates with Sleep Disturbances in Parkinson's Disease Patients

Sleep disturbances and associated factors in patients with Parkinson's disease

AIMS

This study aimed to describe clinical characteristics and sleep quality of Parkinson's Diseases (PD) patients and identify associated factors with sleep quality.

METHODS

A cross-sectional study was conducted at the National Geriatric Hospital, Hanoi, Vietnam, from December 2022 to April 2023. A total of 130 Parkinson's disease patients undergoing treatment at the hospital were invited. Demographic and clinical characteristics were obtained. The diagnosis of sleep disorders was based on the standards outlined in the DSM-V. A multivariate logistic regression model was employed.

RESULTS

90.9 % experienced sleep disorder, with the significant types including insomnia (76.2 %) and restless legs syndrome (56.2 %). The majority of patients suffered two (33.1 %) and one kind of sleep disorder (32.3 %). Most patients experienced sleep disorders after diagnosis of PD (80.0 %). Only having shoulder and neck pain was positively associated with a likelihood of having sleep disturbances (OR=4.87, 95 %CI=1.18-20.15).

CONCLUSION

This study found a high rate of sleep disorders among PD patients in our sample. Shoulder and neck pain was found to be associated with a risk of sleep disorders. Pain management should be performed to improve the sleep quality of PD patients.

Pain in Parkinson disease: a deep phenotyping study

ABSTRACT

In our prospective cross-sectional study, we comprehensively characterized Parkinson disease (PD)-related pain in monocentrically recruited patients with PD using standardized tools of pain assessment and categorization. One hundred fifty patients were systematically interviewed and filled in questionnaires for pain, depression, motor, and nonmotor symptoms. Patients with PD-related pain (PD pain), patients without PD-related pain (no PD pain), and patients without pain (no pain) were compared. Pain was present in 108/150 (72%) patients with PD, and 90/150 (60%) patients were classified as having PD-related pain. Most of the patients with PD (67/90, 74%) reported nociceptive pain, which was episodic (64/90, 71%), primarily nocturnal (56/90, 62%), and manifested as cramps (32/90, 36%). Parkinson disease-related pain was most frequently located in the feet (51/90, 57%), mainly at the toe joints (22/51, 43%). 38/90 (42%) patients with PD-related pain received analgesic medication with nonsteroidal anti-inflammatory drugs being the most frequently used (31/42, 82%) and opioids most effective (70% pain reduction of individual maximum pain intensities, range 22%-100%, confidence interval 50%-90%). All patients received oral PD treatment; however, levodopa equivalent dose showed no correlation with mean pain intensities (Spearman ρ = 0.027, P > 0.05). Our data provide a comprehensive analysis of PD-related pain, giving evidence for mainly non-neuropathic podalgia, which bears the potential to rethink assessment and analgesic treatment of pain in PD in clinical practice.

Pain characterization in patients with Parkinson's disease

BACKGROUND

Patients with Parkinson's disease (PD) often report chronic pain, which is one of the most complex non-motor symptoms. Therefore, this study aims to review the literature on the characteristics of pain in patients with PD.

METHODS

A systematic literature review was conducted following MOOSE recommendations. Observational studies reporting pain in patients with PD were included. No time restrictions were applied, but studies in Portuguese, Spanish, and English were considered. The search was performed in PubMed®, LILACS, and SciELO databases.

RESULTS

Twenty-six articles of observational studies were identified, reporting an average pain prevalence of 67.36%, emphasizing the significance of this symptom in the PD population. Pain was reported in various body regions, including lower limbs, upper limbs, lumbar spine, cervical spine, and other joints. Pain classification varied, encompassing musculoskeletal pain, PD-related pain, neuropathic pain, and dystonic pain, among others.

DISCUSSION

Pain in patients with PD is a prevalent and multifactorial condition, significantly impacting patients' quality of life.

CONCLUSION

Heterogeneity in data across included studies was observed, highlighting the need for additional research to elucidate the underlying mechanisms of pain in patients with PD and develop effective therapeutic strategies to address this symptom and improve the quality of life for individuals living with the disease.

Pain is common in early onset Parkinson's disease and pain severity is associated with age and worsening of motor and non-motor symptoms

The consequences of pain in early onset Parkinson's disease (EOPD) remain under appreciated even though pain may exert an increasingly negative impact on patient quality of life as motor and non-motor symptoms worsen. In this prospective study, we investigate the prevalence and severity of pain in 135 Vietnamese patients with EOPD from three medical centers using the King's PD Pain Scale (KPPS), the Mini Mental Status Exam (MMSE), the Unified Parkinson's Disease Rating Scale (UPDRS) and the Non-Motor Symptoms Scale (NMSS). Pain was reported by 79.3%. The most common subtype of pain was musculoskeletal (70.1%), followed by nocturnal (43.9%), radicular (43.0%), chronic (42.1%), fluctuation-related (34.6%) and orofacial pain (16.8%). Most patients (74.8%) experienced more than one pain subtype. Fluctuation-related pain and orofacial pain were significantly more prevalent among patients with higher Hoehn & Yahr (H&Y) stages (3-5) versus lower H&Y stages (1-2). Pain subtype and severity were not significantly related to gender or age of PD onset. Patients with H&Y stages 3-5 had statistically significantly higher KPPS scores for fluctuation-related pain (p = 0.018) and radicular pain (p = 0.026). Independent associations were found between pain severity and age (p = 0.028), depression severity (p = 0.018), perceptual problems/hallucinations (p = 0.033) and sexual function (p = 0.024). Patients with depression and higher H&Y stages (3-5) had statistically significantly higher mean KPPS scores versus patients without depression and at lower H&Y stages (1-2). Pain may be more common and severe in EOPD patients than previously appreciated. Older age, depression, perceptual problems/hallucinations and sexual dysfunction were independently associated with higher pain severity.

The Underlying Mechanisms of Sleep Deprivation Exacerbating Neuropathic Pain

Pain disrupts sleep, and sleep deprivation or interference can alter pain perception in animals and humans, for example by increasing sensitivity to pain. However, the mechanism by which sleep affects neuropathic pain remains unclear. In this review, we discuss the available evidence from the epidemiologic, clinical, and human, as well as laboratory studies. In previous studies, we have found that sleep deprivation affects various injurious systems, including opioids, dopaminergic, immune, orexins, hypothalamic-pituitary-adrenal axis, and adenosine. At the same time, these systems play a crucial role in neuropathic pain regulation. In the complex interactions between these neurobiological systems, there may be potential regulatory pathways through which sleep deprivation amplifies neuropathic pain. Because of the impact sleep problems and neuropathic pain can have on the patients' quality of life, studying the link between sleep and neuropathic pain is important for neuropathic pain prevention and public health.

Axial postural abnormalities and pain in Parkinson's disease

Axial postural abnormalities and pain are two main determinants of poor quality of life in patients with Parkinson's disease (PD). Indeed, a detailed characterization of pain and other non-motor symptoms in patients with PAs has not been provided yet. The aim of this study is to assess the phenomenology of pain and other non-motor symptoms in PD patients with Pisa syndrome and camptocormia compared to PD patients without axial postural abnormality. Forty-five PD participants were equally distributed in three groups: patients with Pisa syndrome (PS), patients with Camptocormia (CC), and patients without postural abnormalities (PD). Pain characteristics were assessed by Kings Parkinson's Pain Scale (KPPS), brief pain inventory (BPI), and numeric pain rating scale (NRS). All participants completed clinical assessments by non-motor symptom scale (NMSS), and movement disorder society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) parts II-III. Patients with and without axial postural abnormalities showed one or more types of pain, being fluctuation, nocturnal, chronic, and musculoskeletal the most frequently reported in Pisa Syndrome and camptocormia. PD group compared with PS and CC groups showed differences in the KPPS, NMSS, BPI pain severity and interference, and NRS total scores. No significant differences were found between PS group compared with CC group with exception of the NMSS total scores. PD patients with Pisa syndrome or camptocormia have a higher burden of musculoskeletal, chronic and fluctuation pain than PD patients without axial postural abnormalities, suggesting different etiologies of pain and possible different treatments.

[Characteristics and treatment of pain in Parkinson's disease]

Pain is a representative non-motor symptom in patients with Parkinson's disease (PD). Pain is one of the most common symptoms that plague patients with PD regardless of the stage of the disease, also it can exacerbate other symptoms, such as depression, anxiety or sleep disturbance, and lead to impaired quality of life. However, pain is often not adequately evaluated and treated. PD patients complain of a wide variety of pain, including both PD-related pain which caused by PD-specific symptoms, for example, rigidity, bradykinesia or motor fluctuation, and PD-unrelated pain, and it can be divided into central and peripheral depending on the site of the disorder. In the medical care of the pain, it is important to evaluate the type and severity of the pain using PD-specific assessment scales such as King's PD pain scale and to consider the evidence-based treatment methods according to the pathophysiology of the pain.

Pain Assessment in Chinese Parkinson’s Disease Patients Using King’s Parkinson’s Disease Pain Scale

Purpose

Patients and Methods

Results

Conclusion

Personalized Assessment of Insomnia and Sleep Quality in Patients with Parkinson's Disease

Sleep disturbances are more common in patients with Parkinson’s disease (PD) than in the general population and are considered one of the most troublesome symptoms by these patients. Insomnia represents one of the most common sleep disturbances in PD, and it correlates significantly with poor quality of life. There are several known causes of insomnia in the general population, but the complex manifestations that might be associated with PD may also induce insomnia and impact the quality of sleep. The treatment of insomnia and the strategies needed to improve sleep quality may therefore represent a challenge for the neurologist. A personalized approach to the PD patient with insomnia may help the clinician to identify the factors and comorbidities that should also be considered in order to establish a better individualized therapeutic plan. This review will focus on the main characteristics and correlations of insomnia, the most common risk factors, and the main subjective and objective methods indicated for the assessment of insomnia and sleep quality in order to offer a concise guide containing the main steps needed to approach the PD patient with chronic insomnia in a personalized manner.

The Neurophysiology of Sleep in Parkinson's Disease

Sleep disturbances are among the most common nonmotor complications of Parkinson's disease (PD), can present in prodromal stages, and progress with advancing disease. In addition to being a symptom of neurodegeneration, sleep disturbances may also contribute to disease progression. Currently, limited options exist to modulate sleep disturbances in PD. Studying the neurophysiological changes that affect sleep in PD at the cortical and subcortical level may yield new insights into mechanisms for reversal of sleep disruption. In this article, we review cortical and subcortical recording studies of sleep in PD with a particular focus on dissecting reported electrophysiological changes. These studies show that slow-wave sleep and rapid eye movement sleep are both notably disrupted in PD. We further explore the impact of these electrophysiological changes and discuss the potential for targeting sleep via stimulation therapy to modify PD-related motor and nonmotor symptoms. © 2021 International Parkinson and Movement Disorder Society.

An overview of pain in Parkinson's disease

Pain is a common non-motor symptom of Parkinson's disease (PD) and the prevalence of pain among PD patients varies because of the disease stage, co-morbidities, and evaluating tools. Risk factors for pain in PD include an early age of onset, long disease duration, motor complications, concomitant depressive symptoms, female gender, and associated medical conditions. In patients with PD, pain can be classified as musculoskeletal pain, chronic body pain (central or visceral), fluctuation-related pain, nocturnal pain, orofacial pain, pain with discolouration/oedema/swelling, and radicular/neuropathic pain; musculoskeletal pain as the most common type. Potential underlying mechanisms include a disruption of peripheral nociception and alterations in central pain threshold/processing. Genetic polymorphisms in genes that confer pain susceptibility might also play a role in the occurrence of pain in PD. In advanced stage of patients with PD, polyneuropathy could occur in patients using high dosage of levodopa. Pain often correlates to other non-motor symptoms of PD, including depression, sleep, and autonomic symptoms. Dopaminergic drugs, non-dopaminergic medications, botulinum toxin, deep brain stimulation, and physiotherapy have shown some benefits for certain types of PD-related pain. An increased awareness of pain as a common non-motor symptom of PD provides further insights into sensory system dysregulation in this disease. In this review, we aim to summarizes the clinical features of pain in patients with PD and emphasize the latest evidence of pain related to levodopa treatment.

Sleep disturbances in Parkinson's disease are associated with central parkinsonian pain

Introduction

Sleep disturbances and pain are common non-motor symptoms in Parkinson’s disease (PD). This study aimed to explore the association between these two symptoms in a cohort of patients with PD.

Materials and methods

The Parkinson’s Disease Sleep Scale (PDSS-2) was used to identify sleep disturbances in a series of 229 PD patients. The identification and characterization of pain was performed by a semi-structured interview and by the application of the Ford classification and the Brief Pain Inventory (BPI). The Unified Parkinson’s Disease Rating Scale-III, Hoehn & Yahr (H&Y), and Schwab and England Independence Scale were used to assess motor symptoms and functional independence in off and on conditions. The Hospital Anxiety and Depression Scale (HADS) and SF-36 were applied to screen for anxiety and depression and to evaluate the quality of life. Non-parametric tests were used for group comparisons and logistic regressions were applied to explore predictors of sleep disturbances.

Results

Seventy-five (33%) patients had clinically relevant sleep disturbances (PDSS-2≥18) and 162 patients (71%) reported pain. Of those with pain, 38 (24%) had central parkinsonian pain. PD patients with sleep disturbances experienced more pain and had more severe motor symptoms, lower functional independence, more anxiety and depression symptoms, and worst quality of life. Among patients with pain, central parkinsonian pain was the subtype of pain with the highest odds of sleep disturbances, even when taking into account motor symptoms (H&Y off), motor fluctuations, intensity of pain (BPI), and symptoms of anxiety and depression (HADS).

Conclusions

The association between pain and sleep disturbances in PD appears to be dependent on subtype of pain. The close relationship between central parkinsonian pain and sleep disturbances in PD raises the possibility of common pathophysiological mechanisms. A better understanding of the relationship between sleep disturbances and central parkinsonian pain may contribute to the development of new care strategies in PD patients.

Comorbid fibromyalgia: A qualitative review of prevalence and importance

Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However, there is increasing report of FM associated with other diseases that are not defined by chronic pain. This qualitative review examines the evidence for comorbid FM in illness, and where available the effect of FM on the primary disease. Other than for musculoskeletal disorders, the published literature reporting an association of FM with illness is limited with scanty reports for some neurological, gastrointestinal, mental health and other overlapping pain conditions. Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases. When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed.

SIGNIFICANCE

Comorbid fibromyalgia (FM) in other medical conditions is largely unrecognized. When reported as accompanying rheumatic diseases, FM adversely affects global health status. With limited reports of comorbid FM with other conditions, neglect to diagnose comorbid FM may misdirect treatments.

First comprehensive tool for screening pain in Parkinson's disease: the King's Parkinson's Disease Pain Questionnaire

BACKGROUND AND PURPOSE

Pain is highly prevalent in Parkinson's disease (PD), impacting patients' ability, mood and quality of life. Detecting the presence of pain in its multiple modalities is necessary for adequate personalized management of PD. A 14-item, PD-specific, patient-based questionnaire (the King's Parkinson's Disease Pain Questionnaire, KPPQ) was designed corresponding to the rater-based KPP Scale (KPPS). The present multicentre study was aimed at testing the validity of this screening tool.

METHODS

First, a comparison between the KPPQ scores of patients and matched controls was performed. Next, convergent validity, reproducibility (test-retest) and diagnostic performance of the questionnaire were analysed.

RESULTS

Data from 300 patients and 150 controls are reported. PD patients declared significantly more pain symptoms than controls (3.96 ± 2.56 vs. 2.17 ± 1.39; P < 0.0001). The KPPQ convergent validity was high with KPPS total score (r_S  = 0.80) but weak or moderate with other pain assessments. Test-retest reliability was satisfactory with kappa values ≥0.65 except for item 5, Dyskinetic pains (κ = 0.44), and the intraclass correlation coefficient (ICC) for the KPPQ total score was 0.98. After the scores of the KPPS were adapted for screening (0, no symptom; ≥1, symptom present), a good agreement was found between the KPPQ and the KPPS (ICC = 0.88). A strong correlation (r_S  = 0.80) between the two instruments was found. The diagnostic parameters of the KPPQ were very satisfactory as a whole, with a global accuracy of 78.3%-98.3%.

CONCLUSIONS

These results suggest that the KPPQ is a useful, reliable and valid screening instrument for pain in PD to advance patient-related outcomes.