Pain Rehabilitation for Parkinson's Disease

by Dr Nathan Johns

Chronic pain and Parkinson's disease are both conditions that affect the central nervous system and can alter movement and thinking patterns. Chronic pain affects 20% of all Australians but is even more common in people with Parkinson’s disease affecting up to 80% of people (1). Fortunately there is effective pain treatment available.

Parkinson’s disease (PD) has been estimated to affect 0.5% of Australians over the age of 50 and almost 1% after the age of 70 (2). It is a progressive neurodegenerative condition and is one of the leading causes of neurological disability. This is due to the effects of PD on the autonomic nervous system, the brain and the brainstem. These changes to the nervous system can lead to impairments of movement, balance, co-ordination, speech, swallowing, cognition, bowel and bladder function.

Pain may even precede the onset of motor symptoms in PD. Pain and other non-motor symptoms can be easily overlooked in the assessment and management of people with PD.  In a pain prevalence study, over 70% of patients with PD reported back pain of a moderate severity or greater (3). Other studies have found that chronic pain is present in 40-85% of patients with PD (4). Due to impairments of balance and movement, falls are common in the PD population and can lead to musculoskeletal injury and further pain (5). Chronic pain in people with PD is often associated with sleep disturbance, anxiety and depression and results in a reduced quality of life.

Chronic pain may be related to musculoskeletal conditions such as osteoarthritis and back pain, have a neuropathic cause or be related to abnormal movements and postures specifically related to PD (6). Pain may also be due to a central neurological cause specific to Parkinson's. Dopamine, a brain neurotransmitter, plays a role in areas of the brain that are involved in modulating the pain experience, principally in the basal ganglia (7). Large reductions in dopamine levels are seen in the basal ganglia (as well as other parts of the brain) in people with Parkinson’s disease. Treating people with PD with L-dopa (which increases dopamine levels) has been shown to improve the response to noxious stimuli and reduce pain from dystonia (painful muscle spasms) and remains an important part of pain treatment (8).

There is a lack of scientific evidence on specific interventions to reduce or alleviate chronic pain in people with Parkinson’s Disease but chronic pain treatment should follow the rehabilitation biopsychosocial approach used to treat people with chronic pain without PD. Given the complex nature of PD however, each pain program needs to be adapted to the individual and their specific area of pain. Pain can be particularly difficult to treat in people with PD due to some of the common Parkinson’s co-morbidities such as hallucinations, orthostatic hypotension, constipation, cognitive impairment, depression and medication sensitivity (9) but fortunately, pain treatment can be successful.

Pain management includes a multidimensional assessment of the individual and development of a multidisciplinary rehabilitation program.

The initial assessment is aimed at determining any precipitants or perpetuating factors of pain, evaluating the effect of pain on function and quality of life and prescribing a program of treatment. Fundamentally, a pain rehabilitation program for parkinson’s disease focuses on improving movement patterns, reducing stress and improving the brain’s ability to reduce pain.

Medical treatment may involve further investigation for a specific cause of pain. It may involve medication use such as levodopa (eg. Madopar and Sinemet), using simple analgesics, stronger analgesics and neuropathic agents (10). It may involve a reduction in medication use to improve cognitive function and reduce side effects. 

Physiotherapy interventions to improve movement patterns in people with PD such as balance training, cueing, strengthening and aerobic training have been shown to significantly improve balance, reduce disability, improve functional reach and reduce motor symptoms (11). These changes can correct some of the biomechanical dysfunction leading to pain. Improving gait and balance can lead on to improving fitness and taking part in more intensive programs designed to unlock the neuroplastic ability of the brain (see below). 

Management of depression and anxiety is an important focus for psychological treatment in Parkinson’s disease and some of the newer anti-depressants may also independently improve pain (10). Cognitive behavioural therapy (CBT) for people with PD and depression or anxiety has been found to be beneficial in improving symptoms for up to 12 months following therapy (12). CBT and mindfulness treatments have also been found to be effective in other groups of people with chronic pain (13, 14). Psychological treatment in pain management focuses on reducing stress and retraining the brain to reduce pain.

Brain neuroplasticity may be important in slowing the progress of Parkinson’s disease and reducing its impact on function.

An intensive 4 week rehabilitation treatment program in the early stages of Parkinson’s disease, when compared with medication only treatment, demonstrated improvements in motor function, movement and activities of daily life over the following 2 years. The rehabilitation treatment appeared to have a neuroprotective effect - that is, it reduced the progression of Parkinson’s disease whereas the medication alone did not affect progression (15). Generally, neuroplasticity treatments involve higher intensity and frequency of training to achieve lasting, positive changes to brain structure and function. This counteracts the negative neuroplasticity changes to the brain and spinal cord involved in the development of chronic pain.  Fortunately, the brain can change back to normalise structure and function with effective pain treatment (16). Another high intensity training program using a body weight supported harness combined with treadmill training in people with PD demonstrated not only improvements in walking but neuroplasticity changes in the brain after only 8 weeks of training (17, 18).

A new style of exercise training in Parkinson’s disease called BIG has been found to reduce bradykinesia and improve scores on the timed up and go (TUG) test and 10 metre walk test (19). BIG training involves four hour long sessions a week for 4 weeks with the aim of improving the amplitude of physical movements and the training is likely to lead to neuroplasticity changes.

So with a comprehensive assessment and multidisciplinary rehabilitation plan, we can enable people with Parkinson's disease to move better, reduce stress, improve function and reduce pain. 


References

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2. Mehta P, Kifley A, Wang JJ, Rochtchina E, Mitchell P, Sue CM. Population prevalence and incidence of Parkinson's disease in an Australian community. Intern Med J. 2007;37(12):812-4.

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11. Tomlinson CL, Patel S, Meek C, Clarke CE, Stowe R, Shah L, et al. Physiotherapy versus placebo or no intervention in Parkinson's disease. Cochrane Database Syst Rev. 2012;7:CD002817.

12. Troeung L, Egan SJ, Gasson N. A waitlist-controlled trial of group cognitive behavioural therapy for depression and anxiety in Parkinson's disease. BMC Psychiatry. 2014;14:19.

13. Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study. Pain. 2008;134(3):310-9.

14. Bernardy K KP, Busch AJ, Choy EHS, Häuser W. Cognitive behavioural therapy for fibromyalgia. Cochrane Database of Systematic Reviews. 2013(9).

15. Frazzitta G, Maestri R, Bertotti G, Riboldazzi G, Boveri N, Perini M, et al. Intensive rehabilitation treatment in early Parkinson's disease: a randomized pilot study with a 2-year follow-up. Neurorehabil Neural Repair. 2015;29(2):123-31.

16. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-15.

17. Fisher BE WA, Salem GJ, Song J, Lin C-H, Yip J, Cen S, Gordon J, Jakowec M, Petzinger G. The Effect of Exercise Training in Improving Motor Performance and Corticomotor Excitability in People With Early Parkinson’s Disease. Arch Phys Med Rehabil. 2008;89:1221-9.

18. Petzinger GM, Fisher BE, Van Leeuwen JE, Vukovic M, Akopian G, Meshul CK, et al. Enhancing neuroplasticity in the basal ganglia: the role of exercise in Parkinson's disease. Mov Disord. 2010;25 Suppl 1(01):S141-5.

19. Georg Ebersbach AE, Daniela Edler, Olaf Kaufhold, Matthias Kusch, Andreas Kupsch, and Jo ̈rg Wissel. Comparing Exercise in Parkinson’s Disease—The Berlin BIG Study. Movement Disorders. 2010;00(00).



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