Dear Listfriends,
Dr. Lieberman has written a new book, soon to be published, and has
provided the following exerpt. In light of the recent conversations on
pain, it is good to know that a leading specialist acknowledges and
addresses this issue.
--------------------
dear friends
 the following is an excerpt from my book on parkinson disease
 i would appreciate any comments Parkinson Disease
          (1) Introduction
        It’s said, “Pain and PD don’t go together.”  And when pain
appears, its
said to be
something else, “arthritis, bursitis, a “bad back”, a “frozen shoulder,”
fibromyalgia, a
“pinched nerve,”a sprained muscle, or nerves.” But pain is part of PD,
and
it has many
forms.   In Chapter 1 you met Melvin, the state senator who’s PD started
with shoulder pain,
pain his doctor’s attributed to an old football injury.  He was treated
with anti-inflammatory
drugs, arthritis drugs, acupuncture, exercise,  massage, and pain killer
to
no avail. It wasn’t
until Melvin was diagnosed with PD, and his pain disappeared on Sinemet,
that it was
attributed, correctly to PD.  In Chapter 5 you learned about discomfort
of
Restless Legs, a
condition associated with PD.  And you learned about the cramping pain
of
dystonia: neck
pain, leg pain, and arm pain.
        How common is  pain is PD?  In my own experience 50% of people
with PD at
one
time complain of pain, and in perhaps 50% of them, 25% of all people
with
PD, the pain is
related to PD  and not something else.  The pain’s related to PD, if it
fits a  pattern, if it’s
worse where PD’s worse, if it’s relieved by PD drugs such as Sinemet
plus
Comtan, if
there’s no other cause.
          (2) The Pain of Rigidity
        In the beginning,  before you’re diagnosed with PD, like Melvin
you may
complain
of a dull pain, like a sprain. The pain may be described as aching,
gnawing, or nagging.  The
pain is usually confined to a shoulder, the neck, the back, or a hip.
These are either major
weight bearing regions (the back, the hip). Or they’re pivots around
which
multi- directional
movements occur:  side-to-side, up-and-down, back-and-forth,
around-and-around. These
pivots are the shoulder, the neck, and to a lesser degree the hip. The
elbows and knees are
pivots, but uni-directional movements: back-and-forth (flexion and
extension).
        This pain is probably related to the rigidity of PD which
results in the
muscles
becoming stiffer, “less elastic”, harder and more painful for them to
move.
This type of pain
“magically” disappears when Sinemet plus Comtan or a dopamine agonist is
started.
        (3) The Pain of Dystonia
        Before you’re diagnosed,  you may complain of a pain different
from
Melvin. The
pain may be described as cramping, sharp, stabbing, or throbbing.  It’s
more intense than
Melvin’s pain. The pain is usually confined to one or both calves, or
forearms, or thighs, or
upper arms. This pain is probably related to the dystonia of PD which
results in the muscles
becoming hard. This  pain also magically disappears when Sinemet plus
Comtan or a
dopamine agonist is started.  Dystonia is different from rigidity.
Although
both make the
muscles  hard, in rigidity the hardness results from the muscles
becoming
“less elastic”,
whereas in dystonia it results from the muscles contracting without
relaxing.   You may not
be able to tell or describe the difference, but a neurologist with an
EMG
(an
electromyogram,  “a cardiogram of the muscle) can.
        Dystonia of the calves, forearms, thigh, or upper arms,  may be
an early
symptom of
PD usually in people below age 40 years. It may appear in PD people who
are
on  Sinemet.
Usually it appears as Sinemet “wears off,” typically in the early
morning
when Sinemet
levels are low.  This is called an “off dystonia.”  It’s worse on the
side
more affected by PD.
It’s  is treated by adding Comtan or a dopamine agonist to prolong
Sinemet’s effect.  The
pain of dystonia can appear as Sinemet peaks, called “on dystonia.”
It’s
harder to treat
requiring re-arranging all your drugs to reduce the “highs” and “lows”
of
Sinemet.
        (4) Describe the Pain
        Only you feel the pain, only you can describe it.  Be as
specific as you
can.  The
following is helpful.
        Location: Where does it hurt most?  The shoulder?  The Hip?  The
Back?
        Does it stay in one place or does it radiate?  If so, where?
From the
shoulder down
the arm?  From the back to the hip?  Knowing how a pain radiates, is
like
knowing the road
on which a car travels.
        Intensity: How bad is it?  Describe it on a scale from “0" to
“10", where
“0" is no
pain, and “10" feels like your arm (or leg) was “yanked-off”, or your
skin
was “ripped off.”
The pain of PD is usually a 4, or 5, or 6, or 7.  It’s never a 10.
        Duration: There are two parts.
        1.  How long have you had the pain? Hours?  Days?  Weeks?
Years?
        2.  During a typical day, how long does it last?  From the time
you get
till breakfast?
Till lunch?  Till dinner?  All day?
        Associations: Is the pain associated with discoloration,
inflammation,
redness,
swelling, or warmth of the overlying skin?   The pain of PD shouldn’t
be
associated with
any of the above.
        Position: What, if any, positions make it better.  What, if any,
make it
worse.
        Quality: There are many ways to describe pain. Some have special
meaning:
Words
used include:  aching, biting, burning, cramping (like a Charlie-horse)
,
griping (like being
caught in between a pair of pliers), hurting, nipping, pinching,
ripping,
smarting, stabbing,
and throbbing.
        (5) Unusual Pain
          Unusual pain may occur in PD and may be related to muscle
spasm
(from dystonia)
 with pressure on an underlying nerve.  Although it’s the muscle that’s
in
spasm, the pain is
from the nerve.  The pain’s more intense than a muscle spasm, and
radiates
along the nerve.
The following may occur.
        Spasm of the  piriformis  muscle (in the buttock) with pressure
on the
sciatic nerve
mimicking the pain from a herniated disc.
        Spasm of the gastrocnemius muscle (in back of the calve) with
pressure on
the
peroneal nerve or spasm of the tibialis muscle (in front of the calve)
with
pressure on the
tibialis nerve causing calve or foot pain.   This may be responsible for
the intense leg or foot
pain people experience when Sinemet “wears- off.”
        Spasm of the pronator muscle in the forearm with pressure on the
median
nerve, or
spasm of the extensor muscles of the wrist with pressure on the radial
nerve with pain down
the forearm.
        If spasm of a muscle is the cause of the underlying nerve pain,
the
treatment is
injecting botulinum toxin into the muscle, reducing the spasm and
freeing-up the nerve.
        A diffuse, not well localized, burning or throbbing pain may
sometimes
occur
in an arm or a leg, or across the chest. Whether this is related to PD,
or
anxiety, or
depression is difficult to pin down. It probably results from a
disordered
Autonomic Nervous
System.
        (6) Treatment
          Pain resulting from PD usually respond to PD medication:
Sinemet
plus Comtan or
a dopamine agonist.  Pain that responds in part, or pain that’s not PD,
may
be treated as such
pain is usually treated. Because many PD people have “sensitive
stomachs”
(see The
Stomach in Parkinson), I prefer drugs such as Celebrex or Vioxx, drugs
that
decrease pain
but rarely  upset the stomach or cause bleeding.
          Anxiety and depression make pain worse, the pain from
rigidity,
or dystonia, or a
          disordered Autonomic Nervous System.  Master your anxiety, or
your depression
          and your pain may disappear.





--
Kathrynne Holden, MS, RD
Author: "Eat well, stay well with Parkinson's disease"
"Constipation and Parkinson's" --  audiocassette & guidebook
"Guidelines for Medical Nutrition Therapy for Parkinson's
disease" & Risk Assessment Tools
"Risk for malnutrition and bone fracture in Parkinson's
disease," J Nutr Elderly. V18:3;1999.
http://www.nutritionucanlivewith.com/