MEDLINE Abstracts: Pain Associated With Parkinson's Disease
MEDLINE Abstracts: Pain Associated With Parkinson's Disease
What's the latest on Parkinson's Disease-related pain? Find out in this easy-to-navigate collection of recent MEDLINE Abstracts compiled by the editors at Medscape Neurology & Neurosurgery.
Ford B
Clin Neurosci. 1998;5(2):63-72
Pain, defined as an unpleasant or distressing sensory experience, has been recognized as feature of Parkinson's disease (PD) since the first descriptions of the disorder. Pain is estimated to occur in approximately 40% of patients with PD, and in a minority of individuals becomes severe enough to overshadow the motor symptoms of the disorder. Recent studies based on patients' descriptions of pain have enabled a classification of painful sensations into 1 or more of 5 categories: musculoskeletal pain, neuritic or radicular pain, dystonia-associated pain, primary or central pain, and akathitic discomfort. The existence of a central pain syndrome, intrinsic to PD, finds support in a collection of case reports, but the precise mechanism is unknown, and a correlation with pathology has not been made. This review describes the clinical features of the pain syndromes in PD, and provides a framework for evaluating, classifying, and treating painful symptoms in PD.
Factor SA, Molho ES
Am J Emerg Med. 2000 Mar;18(2):209-215
Parkinson's disease (PD) is a chronic progressive neurological disorder characterized by tremor, muscle rigidity, slowness of movement (bradykinesia), and gait instability. In early disease, PD is well managed in an office setting, however, as the disease progresses, a variety of syndromes may result in emergency department visits. The scenarios most likely to require an emergent evaluation are severe motor "off" periods with immobility, involuntary movements (dyskinesia), psychosis, acute confusion, panic disorder, and pain. Other less frequent presentations are also discussed. This article uses illustrative cases to provide a framework to discuss emergency department diagnosis and management issues in caring for these patients.
Favre J, Burchiel KJ, Taha JM, Hammerstad J
Neurosurgery. 2000 Feb;46(2):344-533; discussion 353-355
Objective: Pallidotomy has recently regained acceptance as a safe and effective treatment for Parkinson's disease symptoms. The goal of this study was to obtain the patients' perspective on their results after undergoing this procedure. Special attention was focused on the potential complications and the respective advantages and risks of unilateral versus bilateral pallidotomy.
Methods: Fifty-six patients were studied during a 2-year period; 44 completed the evaluation, with a median follow-up of 7 months. Of these patients, 22 underwent unilateral pallidotomy, and 17 had bilateral simultaneous pallidotomy. Five patients who underwent staged bilateral pallidotomy were excluded from the statistical analysis, because the number of patients was considered too small for analysis. The procedures were performed with magnetic resonance imaging determination of the target, combined with physiological confirmation, including microelectrode recording.
Results: According to Visual Analog Scale scores, unilateral pallidotomy significantly improved dyskinesias (P < 0.05) but no other symptoms. Simultaneous bilateral pallidotomy improved slowness, rigidity, tremor, and dyskinesias (P < 0.05) but worsened speech function (P < 0.05). According to the patients' most frequently chosen answers to multiple-choice questions, unilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," and the duration of "off periods," but it worsened the volume of the voice and articulation, increased drooling, and reduced concentration. Bilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," duration of "off periods," and the amount of medication taken, but it increased drooling and worsened the volume of the voice, articulation, and writing. Subjective visual disturbance was noted in 36 and 41% of patients who underwent unilateral and simultaneous bilateral pallidotomy, respectively. Globally, the result of the procedure was rated "good" or "excellent" by 64% of the patients who underwent unilateral pallidotomy and by 76% of the patients who underwent bilateral pallidotomy. An age less than 70 years was a positive prognostic factor for the global outcome (P < 0.05), as were severe preoperative dyskinesias (P < 0.05).
Conclusions: This study confirms that, from a patient standpoint, unilateral and simultaneous bilateral pallidotomy can reduce all the key symptoms of Parkinson's disease (i.e., akinesia, tremor, and rigidity) and the side effects of L-dopa treatment (i.e., dyskinesias). Preoperative severe dyskinesias and younger age are positive prognostic factors for a successful outcome. Simultaneous bilateral pallidotomy was more effective than unilateral pallidotomy regarding tremor, rigidity, and dyskinesias, but it conferred a higher risk of postoperative speech deterioration.
Clifford TJ, Warsi MJ, Burnett CA, Lamey PJ
Gerodontology. 1998;15(2):73-78
Objective: The purpose of the study was to determine the prevalence of burning mouth (BM) in a population of Parkinson's Disease (PD) sufferers and also to assess the use of pain profiles in identifying the type of burning sensation experienced.
Design: Subjects were surveyed by means of a one shot postal questionnaire for which ethical approval had previously been granted. Anonymity was guaranteed and therefore no attempt was made to follow up non-respondents.
Main Outcome: BM was reported by 24% of respondents. The pain profiles were completed by 17 BM sufferers.
Conclusion: Burning mouth is reported to occur in 24% of PD sufferers which is 5 times greater than that of the general population. The reason for this is uncertain but the result has implications for the future care of PD patients and indicates the need for increased dental input at PD outpatient clinics.
Reuter I, Ellis CM, Ray Chaudhuri K
Acta Neurol Scand. 1999 Sep;100(3):163-167
Objectives: Nocturnal disabilities leading to fragmented sleep arising from parkinsonian off period related complications are common, under-reported and are difficult to treat. In this study, we evaluate the use of nocturnal continuous subcutaneous overnight apomorphine infusion in Parkinson's disease and restless legs syndrome.
Methods: Six parkinsonian patients and 2 patients with restless legs syndrome with nocturnal disabilities refractory to conventional oral therapy were assessed using a sleep diary while on standard treatment and during nocturnal apomorphine infusion. Three patients agreed to assessments during placebo infusion with normal saline.
Results: Apomorphine led to a dramatic reduction of nocturnal awakenings, nocturnal off periods, pain, dystonia and nocturia in parkinsonian patients. In patients with restless legs syndrome, apomorphine reduced nocturnal discomfort, reduced leg movements and improved pain and spasm scores significantly. Placebo infusion reproduced pain, nocturnal spasms and sleep disruption.
Conclusion: This study suggests that overnight apomorphine infusion may be effective in overcoming refractory nocturnal disabilities in selected patients with Parkinson's disease and restless legs syndrome.
Honey CR, Stoessl AJ, Tsui JK, Schulzer M, Calne DB
J Neurosurg. 1999 Aug;91(2):198-201
Object: The goal of this study was to determine whether unilateral pallidotomy reduces parkinsonian pain.
Methods: Twenty-one patients suffering from Parkinson's disease (PD) were followed prospectively for 1 year after they had undergone a unilateral pallidotomy to assess the procedure's effect on pain related to PD. Pain unrelated to PD was not studied. Patients scored the level of their PD pain on an ordinal scale (0-10 points) preoperatively and 6 weeks and 1 year postoperatively. The results were analyzed using Wilcoxon's paired-ranks test (with Bonferroni correction) and showed a significant reduction in overall pain scores at 6 weeks (p < 0.001) and 1 year (p = 0.001) following pallidotomy. Various types of PD pain are described and their possible pathophysiological mechanisms are presented.
Conclusions: Unilateral pallidotomy significantly reduces pain attributable to Parkinson's disease.
Tandberg E, Larsen JP, Karlsen K
Mov Disord. 1998 Nov;13(6):895-899
Sleep disorders are common and well documented in patients with Parkinson's disease (PD). However, most data on sleep in patients with PD are derived from selected patient populations. This community-based survey evaluated the prevalence of and risk factors for sleep disturbances in an unselected group of 245 patients with PD and two control groups of similar age and sex distribution: 100 patients with another chronic disease (diabetes mellitus) and 100 healthy elderly persons. Nearly two thirds of the patients with PD reported sleep disorders, significantly more than among patients with diabetes (46%) and healthy control subjects (33%). About a third of the patients with PD rated their overall nighttime problem as moderate to severe. The most common sleep disorders reported by the patients with PD were frequent awakening (sleep fragmentation) and early awakening. Sleep initiation showed no significant difference compared with the control groups. Pain and cramps were not more prevalent among the patients with PD, but they were more likely to report sleep disturbed by myoclonic jerks. Use of sedatives was common in all three groups but significantly higher in the PD group than in the healthy elderly. Symptoms of depression and duration of levodopa treatment showed a significant correlation with sleep disorders in the PD group. This community-based study confirms that sleep disorders are common and distressing in patients with PD. The strong correlation between depression and sleep disorders in patients with PD underlines the importance of identifying and treating both conditions in these patients.
Trist DG
Pharm Acta Helv. 2000 Mar;74(2-3):221-229
Glutamic acid is the major excitatory neurotransmitter in the mammalian central nervous system (CNS). Specific receptors bind glutamate, and some of these, when activated, open an integral ion channel and are thus known as ionotropic receptors. Within the ionotropic family of glutamate receptors, three major subtypes have been identified using classical specific agonist activation, selective competitive antagonists together with their structural heterogeneity. These receptors have thus been named N-methyl-D-aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) and kainate receptors. The NMDA receptor has sites in addition to its agonist-binding site and these seem to either positively or negatively modulate the agonist effect. The NMDA receptor also is unique in that another amino acid, glycine, acts as a co-agonist with glutamate. Changes in glutamate transmission have been associated with a number of CNS pathologies; these include, acute stroke, chronic neurodegeneration, chronic pain, depression, drug dependency, epilepsy, Parkinson's Disease and schizophrenia.
What's the latest on Parkinson's Disease-related pain? Find out in this easy-to-navigate collection of recent MEDLINE Abstracts compiled by the editors at Medscape Neurology & Neurosurgery.
Ford B
Clin Neurosci. 1998;5(2):63-72
Pain, defined as an unpleasant or distressing sensory experience, has been recognized as feature of Parkinson's disease (PD) since the first descriptions of the disorder. Pain is estimated to occur in approximately 40% of patients with PD, and in a minority of individuals becomes severe enough to overshadow the motor symptoms of the disorder. Recent studies based on patients' descriptions of pain have enabled a classification of painful sensations into 1 or more of 5 categories: musculoskeletal pain, neuritic or radicular pain, dystonia-associated pain, primary or central pain, and akathitic discomfort. The existence of a central pain syndrome, intrinsic to PD, finds support in a collection of case reports, but the precise mechanism is unknown, and a correlation with pathology has not been made. This review describes the clinical features of the pain syndromes in PD, and provides a framework for evaluating, classifying, and treating painful symptoms in PD.
Factor SA, Molho ES
Am J Emerg Med. 2000 Mar;18(2):209-215
Parkinson's disease (PD) is a chronic progressive neurological disorder characterized by tremor, muscle rigidity, slowness of movement (bradykinesia), and gait instability. In early disease, PD is well managed in an office setting, however, as the disease progresses, a variety of syndromes may result in emergency department visits. The scenarios most likely to require an emergent evaluation are severe motor "off" periods with immobility, involuntary movements (dyskinesia), psychosis, acute confusion, panic disorder, and pain. Other less frequent presentations are also discussed. This article uses illustrative cases to provide a framework to discuss emergency department diagnosis and management issues in caring for these patients.
Favre J, Burchiel KJ, Taha JM, Hammerstad J
Neurosurgery. 2000 Feb;46(2):344-533; discussion 353-355
Objective: Pallidotomy has recently regained acceptance as a safe and effective treatment for Parkinson's disease symptoms. The goal of this study was to obtain the patients' perspective on their results after undergoing this procedure. Special attention was focused on the potential complications and the respective advantages and risks of unilateral versus bilateral pallidotomy.
Methods: Fifty-six patients were studied during a 2-year period; 44 completed the evaluation, with a median follow-up of 7 months. Of these patients, 22 underwent unilateral pallidotomy, and 17 had bilateral simultaneous pallidotomy. Five patients who underwent staged bilateral pallidotomy were excluded from the statistical analysis, because the number of patients was considered too small for analysis. The procedures were performed with magnetic resonance imaging determination of the target, combined with physiological confirmation, including microelectrode recording.
Results: According to Visual Analog Scale scores, unilateral pallidotomy significantly improved dyskinesias (P < 0.05) but no other symptoms. Simultaneous bilateral pallidotomy improved slowness, rigidity, tremor, and dyskinesias (P < 0.05) but worsened speech function (P < 0.05). According to the patients' most frequently chosen answers to multiple-choice questions, unilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," and the duration of "off periods," but it worsened the volume of the voice and articulation, increased drooling, and reduced concentration. Bilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," duration of "off periods," and the amount of medication taken, but it increased drooling and worsened the volume of the voice, articulation, and writing. Subjective visual disturbance was noted in 36 and 41% of patients who underwent unilateral and simultaneous bilateral pallidotomy, respectively. Globally, the result of the procedure was rated "good" or "excellent" by 64% of the patients who underwent unilateral pallidotomy and by 76% of the patients who underwent bilateral pallidotomy. An age less than 70 years was a positive prognostic factor for the global outcome (P < 0.05), as were severe preoperative dyskinesias (P < 0.05).
Conclusions: This study confirms that, from a patient standpoint, unilateral and simultaneous bilateral pallidotomy can reduce all the key symptoms of Parkinson's disease (i.e., akinesia, tremor, and rigidity) and the side effects of L-dopa treatment (i.e., dyskinesias). Preoperative severe dyskinesias and younger age are positive prognostic factors for a successful outcome. Simultaneous bilateral pallidotomy was more effective than unilateral pallidotomy regarding tremor, rigidity, and dyskinesias, but it conferred a higher risk of postoperative speech deterioration.
Clifford TJ, Warsi MJ, Burnett CA, Lamey PJ
Gerodontology. 1998;15(2):73-78
Objective: The purpose of the study was to determine the prevalence of burning mouth (BM) in a population of Parkinson's Disease (PD) sufferers and also to assess the use of pain profiles in identifying the type of burning sensation experienced.
Design: Subjects were surveyed by means of a one shot postal questionnaire for which ethical approval had previously been granted. Anonymity was guaranteed and therefore no attempt was made to follow up non-respondents.
Main Outcome: BM was reported by 24% of respondents. The pain profiles were completed by 17 BM sufferers.
Conclusion: Burning mouth is reported to occur in 24% of PD sufferers which is 5 times greater than that of the general population. The reason for this is uncertain but the result has implications for the future care of PD patients and indicates the need for increased dental input at PD outpatient clinics.
Reuter I, Ellis CM, Ray Chaudhuri K
Acta Neurol Scand. 1999 Sep;100(3):163-167
Objectives: Nocturnal disabilities leading to fragmented sleep arising from parkinsonian off period related complications are common, under-reported and are difficult to treat. In this study, we evaluate the use of nocturnal continuous subcutaneous overnight apomorphine infusion in Parkinson's disease and restless legs syndrome.
Methods: Six parkinsonian patients and 2 patients with restless legs syndrome with nocturnal disabilities refractory to conventional oral therapy were assessed using a sleep diary while on standard treatment and during nocturnal apomorphine infusion. Three patients agreed to assessments during placebo infusion with normal saline.
Results: Apomorphine led to a dramatic reduction of nocturnal awakenings, nocturnal off periods, pain, dystonia and nocturia in parkinsonian patients. In patients with restless legs syndrome, apomorphine reduced nocturnal discomfort, reduced leg movements and improved pain and spasm scores significantly. Placebo infusion reproduced pain, nocturnal spasms and sleep disruption.
Conclusion: This study suggests that overnight apomorphine infusion may be effective in overcoming refractory nocturnal disabilities in selected patients with Parkinson's disease and restless legs syndrome.
Honey CR, Stoessl AJ, Tsui JK, Schulzer M, Calne DB
J Neurosurg. 1999 Aug;91(2):198-201
Object: The goal of this study was to determine whether unilateral pallidotomy reduces parkinsonian pain.
Methods: Twenty-one patients suffering from Parkinson's disease (PD) were followed prospectively for 1 year after they had undergone a unilateral pallidotomy to assess the procedure's effect on pain related to PD. Pain unrelated to PD was not studied. Patients scored the level of their PD pain on an ordinal scale (0-10 points) preoperatively and 6 weeks and 1 year postoperatively. The results were analyzed using Wilcoxon's paired-ranks test (with Bonferroni correction) and showed a significant reduction in overall pain scores at 6 weeks (p < 0.001) and 1 year (p = 0.001) following pallidotomy. Various types of PD pain are described and their possible pathophysiological mechanisms are presented.
Conclusions: Unilateral pallidotomy significantly reduces pain attributable to Parkinson's disease.
Tandberg E, Larsen JP, Karlsen K
Mov Disord. 1998 Nov;13(6):895-899
Sleep disorders are common and well documented in patients with Parkinson's disease (PD). However, most data on sleep in patients with PD are derived from selected patient populations. This community-based survey evaluated the prevalence of and risk factors for sleep disturbances in an unselected group of 245 patients with PD and two control groups of similar age and sex distribution: 100 patients with another chronic disease (diabetes mellitus) and 100 healthy elderly persons. Nearly two thirds of the patients with PD reported sleep disorders, significantly more than among patients with diabetes (46%) and healthy control subjects (33%). About a third of the patients with PD rated their overall nighttime problem as moderate to severe. The most common sleep disorders reported by the patients with PD were frequent awakening (sleep fragmentation) and early awakening. Sleep initiation showed no significant difference compared with the control groups. Pain and cramps were not more prevalent among the patients with PD, but they were more likely to report sleep disturbed by myoclonic jerks. Use of sedatives was common in all three groups but significantly higher in the PD group than in the healthy elderly. Symptoms of depression and duration of levodopa treatment showed a significant correlation with sleep disorders in the PD group. This community-based study confirms that sleep disorders are common and distressing in patients with PD. The strong correlation between depression and sleep disorders in patients with PD underlines the importance of identifying and treating both conditions in these patients.
Trist DG
Pharm Acta Helv. 2000 Mar;74(2-3):221-229
Glutamic acid is the major excitatory neurotransmitter in the mammalian central nervous system (CNS). Specific receptors bind glutamate, and some of these, when activated, open an integral ion channel and are thus known as ionotropic receptors. Within the ionotropic family of glutamate receptors, three major subtypes have been identified using classical specific agonist activation, selective competitive antagonists together with their structural heterogeneity. These receptors have thus been named N-methyl-D-aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) and kainate receptors. The NMDA receptor has sites in addition to its agonist-binding site and these seem to either positively or negatively modulate the agonist effect. The NMDA receptor also is unique in that another amino acid, glycine, acts as a co-agonist with glutamate. Changes in glutamate transmission have been associated with a number of CNS pathologies; these include, acute stroke, chronic neurodegeneration, chronic pain, depression, drug dependency, epilepsy, Parkinson's Disease and schizophrenia.
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