All right, I should start my next talk. Okay, so this is Parkinson's disease. I didn't even realize that people with Parkinson's disease had pain. I just thought it was a movement disorder and I didn't even think that there would be some association with Parkinson's disease and pain. So, anyway, my wife and I actually were asked to give a talk to a Parkinson's disease support group on this topic and that was where my interest started and I started to look into the association. So, in this talk, I'll try to give you some understanding of the prevalence of pain in the Parkinson population, describe the presentation, some causes, and, of course, review some treatments that might be of help. So, this is your typical Parkinson patient and they're all very different. Everybody presents differently. Michael J. Fox is probably the biggest poster child for Parkinson's disease. If you've ever seen some of his interviews, it's really quite dramatic in regards to how it has affected him. The rigidity and trembling of the head, that forward tilting of the trunk, arm swing is reduced, and then maybe some trembling of the extremities, the pill-rolling of the fingers, and then that shuffling gait with short steps which may be altered depending on whether they're on their medications or off their medications. In some cases, where they're off their medications, they can't hardly move at all, and then when they have their medications, they're able to move much more fluently. So, Parkinson's disease is a progressive neurodegenerative disease in which the central nervous system is, there's a degradation of the dopaminergic tract. And so, to treat it, we try to give them back their dopamine. So, we typically utilize levodopa, which is a dopamine precursor, and carbidopa is typically given in addition, and that reduces peripheral conversion of levodopa to dopamine. Now, pain is an interesting term, and I like this. This is through the International Association for the Study of Pain, and they defined it as an unpleasant sensory and emotional experience. And it's associated with actual or potential physical damage. My favorite study that I read was they took healthy volunteers, they had them sitting at a table, and they put their hand on a little pad, and then they went ahead and caused an electric shock to their hands, and they asked them to rate the sensation zero to 10. Was this painful or not? So, five people, hands on the pad, and they started click, click, click, click, click, going up and up and up, and then they would ask, what would you rate that pain? What would you rate that pain? And what was intriguing is that some patients, after one little shock, that's a 10. I can't take it anymore. Other people, go at it, doc. I can hear, this isn't painful. That's no problem at all. You know, so it's intriguing, this emotional aspect, how we perceive pain, even in a situation where the actual physical stimuli is the same for these patients. And I think we see this all the time when we're doing electromyographic studies, right? I mean, it's the same electrical study. It's the same needle. Some people, boy, you know, I can't take it anymore. I can't take it. Other people, boy, they're snoring while we're doing this study. I've got to wake them up to, come on, show me, move your biceps, okay? You know, it's dramatic. So, I think it's important for us to realize this perception of pain, it's unpleasant, it's sensory, but the emotional aspect really impacts what they tell us. We have to always keep that in mind. This is a neat thing, too. You know, I struggle when I see a patient. Let's say we have a patient who has pain down their right leg, and it goes into the lateral foot, and you do a stretch reflex, and there's an absent Achilles reflex, and you feel they have an S1 radiculopathy, and it hurts. It really hurts. And you maybe do your needle examination, and you're going to say, well, there's diminished sensation in the S1 dermatome. So, in that case, we might say that this patient has hypoalgesia, diminished pain in response to a normally painful stimuli, a needle poke. But what about the patient with her pet exhaustor? I hurt, I feel pain in my chest. They're still saying they both have pain, but then you take a little cotton swab, and you rub it across their chest. Oh, my gosh, stop. They can't wear clothing. They can't wear underclothing because the pain is so bad. How might we describe that? Well, that might be the aledinia, perception of pain to stimulate. They're not usually painful, all right? And then maybe we took a needle poke, and we compared one side to the other, and now they're indicating that they have hyperesthesia, admirable increase in sensitivity to stimuli of the senses. That might could be any sense, really light, sound, but the increased sensitivity to pain, that pinprick would be hyperalgesia. So, these are terms that we might use when we're looking and trying to be a little more explicit in how to describe this patient's pain based on our clinical examination and our history. And then we go into dysesthesia, unpleasant abnormal sensation. If we numb up somebody before we do a procedure, then we're creating analgesia, absence of pain in response to stimulation that would be normally painful, but we're actually numbing the area itself. And then hypoesthesia, decrease in normal sensation. So, these are terms that are found, and I would encourage you to utilize them because I think it's helpful to be able to share that with other clinicians for you to look at it down the road and understand when you examine these patients what the patient is experiencing. What is that sensation of pain? Pain measurements are, you know, always different. I think that the pain is the fifth vital sign. That was a big issue that came back into the 90s. We really need to treat pain. Well, the trouble is that most of the time when we were looking at pain as an assessment or this fifth vital sign, what do we have to use? Well, it was the visual analog scale. Well, as we talked about before, that's all over the place. So, somebody could say, I'm at a 10 out of 10. I need my high-strength opioid medication or my IV or whatever it might be. So, the real key with us is are you, I try not even to ask them what their zero to 10 scale is. I want to know how it's impacting their function. Now, there are other scales that are used for Parkinson's patients. There's a non-motor scale questionnaire, a non-motor symptom scale. For Parkinson's, though, there was actually a scale developed specifically for Parkinson's patients based on the types of pain that they experience. So, this was done in the United Kingdom, King's College Parkinson's disease pain scale and questionnaire. And there's also, there's 14 questions measuring severity and the frequency of the Parkinson's specific pain. Now, having said this, I'll be honest with you, I don't use it. But if you're looking at trying to really quantify the patient's pain experience and maybe you're doing a clinical study, maybe you're looking at how the patients respond to your treatment, this would be a really nice way of objectively assessing your pharmacologic or other types of treatments. So, this is a bit hard to see, but I'm going to come up to the slide. So, it describes it in severity and frequency. And then there's various domains of musculoskeletal pain, chronic pain, fluctuation-related pain. And they rate it in severity and frequency, and then they tally it up. And then we continue on to nocturnal pain, oral facial pain, and then also to swelling, edema, discoloration, and then radicular pain. So, they tried to take all of the various pain complaints that they've seen in their patients and then put it into this pain scale and then put numbers to it. And then you would take the severity and the frequency, you multiply them, you get a number, and you go down that list. So, it's nice. If you're focusing your care on Parkinson's patients, it would probably be very helpful to have this fill out in the waiting room to be able to judge treatment and to gain an understanding of how pain is impacting their life. There's also a pain questionnaire, and this is kind of more designed as a quick way to ask patients those questions. So, they correspond to questions on the disease pain scale. And this is items pain around the joints, pain related to internal organs, abdominal pain, generalized nonspecific pain, deep pain, disconnect pain, pain related to abnormal movements, cramps, mainly during the off period. And then also restless leg syndrome, pain while turning in bed. A lot of these patients have problems with sleep, chewing, grinding teeth, maybe a burning mouth syndrome that I didn't even realize existed until I was researching this article. Burning pain in the limbs, shooting pain. And then domains, looking at musculoskeletal pain, do your joints hurt? Is there pain in various regions of the body? Fluctuations, does it come and go? It gives nocturnal pain at night or during the day, orophacial pain, and then various swelling, and then of course, the radicular symptoms. So anyway, this was a nice document. I think it's important to realize if you are looking at the Parkinson's disease patient who are in pain, that this would be a nice document to utilize. So how common is this? It's pretty common. And when you look at this type of assessment, they're looking at, when they compare it to patients in the same age group, people with Parkinson's have a higher frequency of pain than people in the same age group. And what's interesting is that the pain can be more problematic than the motor symptoms. So, you know, the patients, they're struggling to walk, they're moving, you know, they're, you know, doing various movements. But when you ask them, what really bothers you, or what they come to potentially see you isn't necessarily the motor symptoms, it's, I hurt. My shoulder hurts, I can't sleep, I can't eat, whatever it might be. So the actual pain may be more problematic than the motor symptoms. The vast majority, over 70 percent, seem to indicate muscle cramps. So people with Parkinson's disease, about 70 percent of these patients are going to report muscle cramps. Twenty, over 20 percent, dystonic-type posturing, the movement pain associated with that continued involuntary or abnormal posturing, a significant percentage with radicular pain, joint pain, and then even generalized pain. Now, the etiology is, of course, unclear, as we might expect, and these are patients, typically, who are older individuals who already have potentially other preexisting or pre-morbid conditions, arthritis, and maybe degenerative disc disease. So the feeling is that it's related to a variety of different factors, and some of which may actually be related to the lack of dopamine itself. So there's an issue related to dopamine being able to effectively try to modulate painful impulses. So when you have issues about arthritic pain, dopaminergic aspects, and then also the drugs themselves that we treat, the carbidopa, levodopa, the secondary effects of those drugs may actually have some impact in pain, too. So we have to be mindful these drugs are not benign. We don't give it to every patient, because long-term use of these medications could have issues, as well. So the pain, musculoskeletal, neuropathic, radicular pain, arthritic changes, maybe central pain because of the changes in the central nervous system from this lack of dopamine may actually create diffuse pain in various areas of the body in a non-dermatomal or non-peripheral nerve distribution. And then the diskinetic, dystonic-type movements, acathesia also. So musculoskeletal being probably the most common, of course, what we would typically see in our patients, even in the elderly population. Central pain described as aching, cramping, sharper burning, larger regions of the body, non-dermatomal or peripheral nerve distribution. And then the neuropathic radicular pain would be involving specific nerves or nerve roots and described as the numbness, tingling, burning. And this can be seen in spinal stenosis, herniated disc, of course, or spondylosis. So these are individuals who may already have a lot of these symptoms. Now they have Parkinson's, so we may treat them as we typically would for these conditions. But also, we have to be mindful that because of the Parkinson's condition, there may be an increased level of pain due to this hypersensitivity of the dopamine levels. An example of the degenerative disc disease causing compression of the nerves. Dystonia is seen. It's described as an involuntary, prolonged muscle contraction or rigidity. And this may even, pain may be reported from the nociceptors of the muscles themselves, that chronic contraction of the muscles. Maybe some hypoxemia of the muscles or just fatigue of the muscles from this continued repetitive movement that many of these patients experience. So, and then there's acathisia, a sense of restlessness seen at night and primarily involved in the legs. This is a nice description of it. This movement back and forth, maybe pacing, maybe the feet in constant movement. And you can just imagine how disrupted that would be during the day, but even just trying to sleep. And so, this is something that we will see in some of the Parkinson's patients. This is interesting. This atypical pain. I was not aware this existed. It's described as burning mouth syndrome seen in patients with Parkinson's. There's also a kinetic crisis, this chronic movement, muscle cramps, headaches can be seen with Parkinson's at a higher degree, age based. Mechanism is unclear, but we presume that it has something to do with the lack of dopamine. We know that pain sensation is controlled through the basal ganglia and that there's connections to other pain related areas, including the frontal cortex as well. So, we know that our body helps to modulate painful impulses and with the lack of dopamine or the ability to modulate and control pain is impaired. And then, nociceptive pain, musculoskeletal, visceral. Typically, these patients will report that their pain is worse in the morning when there's low dopamine levels or they haven't started their medications. And then, there's a concern that the pain may be due to this reduced nociceptive threshold. And low dopamine may be also some impact of low serotonin, norepinephrine neurotransmitters that are known to be involved in pain modulation that may also be low in this patient population. This is a nice slide indicating normal and abnormal dopamine levels, normal neuron, normal movement, Parkinson's, diminished dopamine, movement disorders, and subsequent pain. So, there is a feeling that dopamine receptors regulate sensation and how we experience pain and low dopamine levels may enhance this propagation of pain resulting in their reported discomfort. So, what about treatment? Well, being rehabilitation physicians, of course, multidisciplinary treatment is going to be the focus. Physical therapy combined with pharmacotherapy. And also, most importantly, is what are the patient expectations? What are they trying to achieve? What are their personal goals? With one of the patients that we saw not too long ago, he came in with a history of Parkinson's. He had lower back pain. He actually had a previous diagnosis of lumbar spinal stenosis. He went to see a surgeon. They operated on him. He had a success. We had an operation for spinal stenosis, but when everything healed, he still had the same residual pain. So, surgery for his spinal stenosis may have corrected the anatomic abnormality, but it did not correct his pain perception. It didn't achieve what he wanted. And what was interesting is he had pain, but his personal goal was not to reduce pain as much as it was because he wanted to walk further. He wanted to improve his walking ability as opposed to necessarily me treating the pain. So, those are things that you need to address. If walking ability is there, then again, optimizing dopaminergic therapy, medications, and then also, of course, trying to focus on any physical therapy treatment. This is a nice diagram documenting where you see low dopamine levels through the actual cross-section of a portion of the brain in the substantia nigra. Reduced substantia nigra is visible in Parkinson's. You can see the staining is diminished in the Parkinson's disease patient. So, we find that cramps and dyskinetic pain seem to be associated with the off periods when they're off their medications or their medication effects are wearing off. And then treatment involves prolonging the on period so that we can improve their pain control and also movement disorder. This was a nice example I saw in one of the textbooks. And this is something that I've seen in my own clinical practice, too. So, a patient had been followed by a physician for three years, pain and stiffness, diagnosed with fibrocytis. Then she was diagnosed with Parkinson's. L-DOPA commenced, marked improvement in motor function and also pain-free for the first time in years. Sixty-two-year-old, pain-free, first time in several years. Then she develops dyskinesia, motor response fluctuation, even described some of the things we talked about earlier, this pain where skin over legs felt extremely sensitive like a fresh sunburn. Pronounced Parkinson's, episodic depression, and each time her medication wore off. But whenever she took her L-DOPA, pain control, movement, everything seemed to improve. So, it's a nice example of what we see. I had a patient who I've been treating for probably 10-plus years with a variety of different types of neck and lower back symptoms. So, we treated with pharmacologic therapy, injection therapy. She ultimately had a spine operation, none of which seemed to do much good. I actually went and placed a spinal cord stimulator in her, which seemed to do pretty good, and she used it for about five years or so. And she was doing reasonably well on this combination of oral medications, spinal cord stimulation, and then she was diagnosed with Parkinson's. She was started on L-DOPA, and then she comes in and she says, I'm not really in any pain. I don't need my medications anymore. So, we stopped all her oral pain medication. She'd been on for years. And then she said, you know, I don't really have any pain anymore. I'm not using my spinal cord stimulator anymore. Can you take it out? So, we took it out. So, she's pain-free all these years because she was diagnosed with Parkinson's, treated with L-DOPA. So, the question always is, is are we missing some of these patients? Because what we are seeing in these chronic pain patients may be the first signs of Parkinson's. It's an interesting thought. And do we trial them on L-DOPA just to see what happens? I don't know. But it is intriguing, you know, when you look into this. So, it's fascinating. So, that was my own personal experience was almost identical to what was seen here. So, these are the medications that are utilized, carbidopa, levodopa, increased dopamine levels, hopefully normalizing their perception of pain, cefenamide, reversible selective MAO inhibitor. This seems to reduce degradation, reuptake of dopamine, works on modulating glutamate, which is a big hot topic in pain control, inhibiting voltage-gated sodium channels, apomorphine stimulating dopamine receptors to reduce the dystonia, Botox, we used commonly for muscle tonicity, dystonia. So, that's also utilized, of course. Entecapone, combined with levodopa, reducing dystonia, increasing central availability to dopamine. So, these are medications. I don't prescribe any of these, but it's nice to know they're out there. Maybe you might have a conversation with a neurologist when they're coming in. They seem to feel like their motor disorder is controlled, but maybe the pain issue. Maybe making a phone call to the neurologist and say, hey, we're doing a great job in their ability to walk and to move around, but their pain is still bothering. Can we look into some other alternative pharmacologic therapies to see if it might help their pain, specifically focused on improving dopamine? And then there's a rotigotine, non-ergot dopamine agonist, stimulating dopamine receptors, reducing off time. So, anyway, there's a lot of stuff out there, and I think it's important to realize there's a lot more than levodopa, carbidopa that might be utilized, not necessarily for movement disorders, but for the pain symptoms they're experiencing. This was an interesting topic that was in some of the articles that I reviewed, cannabinoids, medical marijuana, and that's a big question. I mean, every patient I've seen like at least two or three times a day, I'm fielding questions in medical marijuana. What do you think? My feeling is pretty much what I'll present here. You know, in Florida, it's legal to get a medical marijuana card, and it's legal to go into a dispensary to get it. However, when you go into those dispensaries, you have a lot to choose from. You don't know what the concentration is. You don't know what the dose is. Whether you get a cookie, or a gummy bear, or a liquid, or a weed. I mean, who knows? And how often are you going to take it? A little piece of cookie in the morning, cookie in the afternoon, and whether that cookie was more concentrated with a THC versus another batch? Who knows? And that's really what the struggle is. So, it's certainly the people that are advocates for it talk about it as an option, but high-quality evidence is severely lacking. There was a clinical study, double-blind crossover utilizing cannabis oil, well tolerated, but they could not see any objective or subjective improvement in pain. So, limited evidence might be an option for individuals. I don't dissuade anyone from using it. If they want to try it, then that's up to them. I do, I'm always cautious about combining any type of medical marijuana, THC products with any opioid medication. It's because of the concerns of drug-to-drug interactions. But as of itself, it's an option. But again, we have to be mindful of any potential side effects with it. So, it's out there. So, I'll leave it at that. Restless legs, levodopa, long-acting dopamine can be used to treat this. Amitriptyline or other medications similar in that class, and then of course, Horizon, the long-acting gabapentin is FDA approved for restless legs. So, these are medications also used for post-hypertic neuralgia. The issues with gabapentin, of course, in this age population is it can be very sedating. It might interfere with their balance and their cognition and their visual, their vision. And so you might find that by putting on a gabapentin, you're helping their restless legs, but now they are falling all the time or they're sleeping all the time. So we have to be very cautious with the use of a gabapentin. Bone and joint pain, standard treatment, as we heard about from earlier lectures, physical therapy, the anti-inflammatory medications, opioids, plus or minus, it certainly may have a role. Injection therapy, Tylenol. Non-steroid anti-inflammatory medications certainly effective for inflammatory induced joint pain. The question, of course, in this patient population, is it really an inflammatory condition? And then, of course, we're always concerned about renal disease and gastric, the impact on the GI tract. Opioids, limited utility, these are typically patients who are not that physically active, so there's a risk of opioid-induced constipation. Dependence tolerance, opioid-induced hyperalgesia at higher doses. Hormonal changes, hypergonadism, low testosterone levels. Respiratory suppression, usually not an issue with long-term use, but again, acute use could be an issue. And then, of course, potential cognitive impairment and sedation are always a concern. So it's out there. It could be utilized, but obviously very cautiously and typically not as a first-line treatment. Injections, well, these patients are reporting shoulder pain, knee pain, hip pain. They have the same complaints as many other patients, but seemingly at a higher frequency. So again, it may provide immediate and short-term benefit. There's always the risk of steroid-induced osteopenia, osteoporosis. Obviously, the lecture we had earlier about steroid injections and marcaine and various other anesthetic agents causing further joint destruction. So it may help a little bit, the immunosuppression aspects of it as well. And certainly, there are other treatments, the plasma regenerative protein, stem cells, all that would be considered experimental, but it's certainly being utilized in this patient population for the types of pain that they're reporting. And then, of course, we get back into the other issues of patients with spine pain associated with the Parkinson's. So again, the issues of nerve blocks and radio frequency ablation, epidural steroid injections, all of these certainly can be useful in this patient population if we feel that their pain condition would warrant such intervention. So all of those things would still continue on even with the diagnosis of Parkinson's. Tylenol is something I give a lecture to the geriatric fellows and to the family medicine residents, and part of their geriatric textbook in the slides that I use talks about the value of acetaminophen. It's probably underutilized in the way that they're recommending it. So for an individual who does not have any history of any liver disease, the recommendation in the geriatric population, certainly in the Parkinson population, might be to try acetaminophen. Maximum dose, three grams a day. So what I'm telling many of my patients is get the extra strength Tylenol, 500 milligrams, take two in the morning, two in the middle of the day, two before you go to bed, around the clock, and keep taking it. So a lot of patients take Tylenol, but they hurt, they hurt, then they take the Tylenol, they wait 15, 20 minutes, half hour, then it kicks in, then they don't take it again until they feel pain. So they're chasing their pain. So time-contingent acetaminophen might be a reasonable thing to help reduce pain. Catch it before it becomes a problem and put it on a regular scheduled dose. So it's something to consider and certainly serves as an alternative or an adjunct to anti-inflammatories. Physical therapy. We recommend physical therapy to everybody. And passive progressive resistance exercise has been shown to improve gait initiation in the Parkinson population. It's been able to show improvement in stride length. So physical therapy works from a standpoint of their mobility. Everybody should get physical therapy. And then, and also, Tai Chi. That, the clinical studies with Tai Chi and the Parkinson population, they compared it to resistance training and stretching. Tai Chi was superior in gait, strength, timed up and go, and reduction of falls. So when we, the state of Florida has a Department of Health form that says, not opiate alternatives, and we hand it to every patient, and one of the recommendations is Tai Chi and yoga. So I'm a big advocate for Tai Chi. So I'm always talking about Tai Chi. One of our physicians in this group would give lectures sometimes in the past on Tai Chi. And anyway, it's fantastic. So I would encourage everyone to at least have this discussion with all your patients, but certainly in the Parkinson patient population. But in regards to physical therapy, reducing a person's pain, not so much. So there's a paucity of evidence. Theoretical benefit, right? Ice, heat, teaching them how to use other modalities to help with their pain. Certainly, we know it can improve function and quality of life by improving their mobility and reducing falls. But, you know, we have to understand a lot of these patients are, they're in pain, I want to get treated, I go to physical therapy. Yeah, well, they gave me this and this and this, but I'm still in pain. We have to make sure that we're rephrasing that referral to physical therapy for focusing on function and improvement in mobility. So that's the real key when we're sending it. Don't, we're trying not to let them know that, you know, that we hope it helps with their pain, but we have to make sure the expectations are not necessarily it's going to change your life in that regard. Deep brain stimulation, when I go to the neuromodulation, the NANDS, North American Neuromodulation Society meetings, all these topics on deep brain stimulation. Because why? It's very effective for that tremor that the Parkinson patients experience, a very effective treatment for that. And it's really astounding to have someone have a device like that implanted in their brain. They're, they're moving their arms back and forth and they turn it on and boom, the arm stops moving. It's dramatic. But so the question has always been when they're doing these studies, let's look at pain control. Can, can, when it stops the movement of that arm, stops that tremor, would it also control their pain? So they actually looked in that. And what they do find, it seems to reduce and help musculoskeletal and dystonic pain. So it seems to help. There's a lot, not what I would call statistically significant, but there seems to be evidence to suggest that deep brain stimulation helps. But it doesn't seem to help that central and neuropathic pain, the burning type sensation, maybe movement induced pain. It might help to reduce some of the fatigue that they experience from these abnormal movements. But right now we're not at a position where we're going to send all our Parkinson patients with pain to get deep brain stimulation just for pain. But it is out there and they're looking at it. Maybe different positioning of where that wire would go in the brain. Maybe they'll find something down the road. Other issues with that, of course, are infection. Leads can break. Leads can move in places you don't want them to go. Intracranial hemorrhage is always a concern with any type of surgery. Development of new pain, primarily musculoskeletal. When they're following these patients long term, they're identifying that new pain is developing when they have the implant. Spinal cord stimulation, that's interesting. I, you know, just going through pain and Parkinson and this came up and they're limited clinical. Most of the studies when you're looking at pain in Parkinson with spinal cord stimulators because a patient had fail back syndrome. They had surgery and then they had a stimulator put in, lo and behold, it improved their gait pattern and also seemed to reduce their pain. So they weren't put in specifically for Parkinson. It's really not FDA approved for Parkinson back pain or leg pain or movement disorder. But maybe there's a potential benefit down the road. So we're not quite sure whether spinal cord stimulation will help. And I mentioned that I had a patient who saw me, had the surgery for his back because of spinal stenosis and it didn't help and he had tried all the other treatments. I said, well, we could try spinal cord stimulation. And when I was there at the bedside before we did the procedure, I said, well, you know, it's a successful trial of a spinal cord stimulator would be that we'd want to see a pain reduction by 50 percent and we also want to see an improvement in your mobility and your activities during that trial period. He said, Doc, I don't really have much pain. I mean, it's there, but I really want to walk further. And so this was his follow-up visit when we took the stimulator wire out. A 73-year-old man post-op follow-up status with spinal cord stimulator trial and notes 100 percent pain relief with an ability to walk 22 minutes versus only being able to walk for less than a minute prior to the trial would like to proceed with a permanent implant. That was fascinating. I mean, this is a gentleman who his goal was met with a spinal cord stimulator primarily because of probably this Parkinson condition. So it was really interesting to me in preparing this lecture and then to see this response. So our treatment, of course, is a multidisciplinary treatment approach, physical therapy, pain management, rheumatology, orthopedic neurosurgery, psychology, always trying to focus on the psychological impact. Don't ever forget that. Neurology optimizing pharmacologic therapy. And then that diagram really kind of tries to touch base on all aspects of, of course, what we're doing with the patient. So I want to have you watch a video, which I think was fascinating. The VA has put this out. So can you go ahead and run that video, Matt? So this was through the Veterans Administration. Let's see if it works. OK. All right. Anyway, let's, let's go ahead and take, oh, here we go. Video start. You can leave it just like that, Matt. That's fine. And I thought this video really did a great job in summarizing a lot of what we, what I thought. I signed up for the Army in 1978. I repaired weapons. Anything that the military fired, I fixed. I got hired at the post office in 1983. I enjoyed being a letter carrier for 30 years, and I would have still been doing it if I didn't get blessed with this illness. I couldn't drive my vehicle no more. I couldn't walk. I had no movement in my shoulders. I couldn't perform my route. I'd get on the route and freeze up. It was very hard for me. Myles is a 53-year-old man who has Parkinson's for the last 14 years. He has suffered until about a year ago. He has suffered until about a year ago with really bad motor fluctuations, severe rigidity, tremor, and where he did get to a point where he needed a wheelchair to go long distances, and also he had a lot of pain. Parkinson's disease patients do have a lot of pain. We often don't stress that as the main symptom that we talk about with Parkinson's disease. We often are thinking about their motor problems, their tremor, their slowness, their gait, but pain can be a significant symptom as well. Hi, Mr. Garcia. Hello. Dr. Ashton, nice to see you again. Good. There's a lot of different ways in which pain can be a part of the syndrome, and one of the things that we often see it associated with is that of prominent rigidity. The way a patient would sense rigidity is that they're very tight. It's like you have tight muscles. And dystonia is another type of movement that is associated with co-contraction of muscles. For example, the neck will start activating on one side repetitively, consistently, without stopping, and you start to see maybe that same turn of the head if the neck muscles are dystonic. There's more of an abnormal curling of a joint, of a foot, of a toe. It could curl down. It could curl up. And it's often associated with pain. Myles' worst pain was between his shoulder blades in the back, and it was really troubling to try to sort that out, what the problem was. We didn't know whether it was an orthopedic issue or whether it was his Parkinson's from rigidity or dystonia. The pain that I'm describing in my back area was very intense, very severe. Couldn't get no relief at all. I think that pain as a non-motor symptom is very disabling. Couldn't even get out of bed sometimes because of the pain. So pain and depression definitely correlate strongly with each other. When I was hurting, I was sad. I was doing everything I could to keep positive and thinking that everything was going to loosen up and I was going to get back to work. I wanted to function for my wife and my son and my friends and myself. I wasn't ready to throw in the towel just yet. If the pain is from Parkinson's disease, it often will get better when you give the patient appropriate medication to treat their symptoms. Let's just get an idea of how bad the pain is. Can you give me a sense on the scale here, how much pain you're experiencing right now? I'm having maybe about two to four. And so the goal of a neurologist taking care of a Parkinson's patient is really to help improve their on time so that they don't have these windows in their day where their symptoms are very severe and there won't be as much pain then as well. We're really hoping that when we treat the Parkinson's symptoms with medications, with DBS or with Botox, that we're really relieving that pain syndrome so they can carry on their life. Exercise is one of the most powerful forms of treatment that we have, not just for Parkinson's, for many other health conditions. And we know that if patients do exercise and are moving their bodies more that they will have less pain, actually have less progression of the disease as well. In January, Dr. Glass increased my medication to four tablets every three hours. I was only getting like seven minutes of actual movement. And then I would have to take another four tablets. But it had no relief of pain at all. I went to physical therapy where they prescribed for me a heating pad and a pillow to lie on and try to adjust my spine. I went to acupuncture. I tried yoga. Couldn't get no relief at all. When he had deep brain stimulation surgery about a year ago, the majority of his pain improved. Right away I noticed the DBS inserted in me. I had a free range of motion in my shoulders and the pain, the pain still was there because it was with me for so long that I still felt the pain, but I didn't feel the tightness in my shoulders. After he had DBS, the pain that he had in his mid-thoracic region, and there was also some pain I think in his low back and in his feet, improved dramatically. And so that told us that that pain was probably from rigidity or dystonia. My pain level right now on a scale from one to ten between now and my past pain, would probably be the one and a half to two, considering before I could have been a ten or maybe even a fifteen. And so we're managing him still with Parkinson's medicines. We're offering him Botox. He still needs physical therapy, but he gets around really well. Myles has some dystonia, residual dystonia in his great toe where it's really dorsiflexing up towards his head, and it's quite painful. One of the side effects that I have makes my toe stick up, pokes a hole right through my shoe, and these shoes are only three weeks old. We're now down to offering Botox for him to try to vocally make that muscle more relaxed, and so his toe will be more flat inside his shoes. So we would usually place a needle about right in here, and that's about where the muscle belly is that's controlling this muscle, and then we'd see the toe relax. We can't inject botulinum toxin throughout the whole body to improve pain. Are you ready to go? Here we go. But if there's a specific body region that is impacted by overactive muscles or spasms or dystonia, then you can target those muscles that are overactive. All right, you did a great job. Nice job holding still, and you should start to feel better in about four to five days. You should start to make this toe relax and not continue to pop up like that, okay? I don't think people need to live with their pain, but we as providers can't help you if you don't tell us that you're really suffering. I would spend some time with somebody educating a person who has Parkinson's disease and pain that they're not alone, that there are many, many people who experience the same thing, and that they can do something about it. I'm functioning. Not perfect, but I'm functioning well, and I'm happy as a man to be functioning like this. My 13-year-old son benefits from it, my wife, and I hope everybody that I touch. We know that it's really important to actively engage in a social life and get those loved ones in your lives to stay around you, support you. My pain tolerance is probably pretty high, but my wife coming home to me and my son coming home to me help ease a lot of that. What makes me happy these days is keeping a house, being able to make decisions, paying my bills, being retired even though I'd rather be at work. It's kind of nice being home. Making sure my son gets off to school so I'm not scared anymore. I take a walk to the store, I walk my dog. I have conversations with people, try to enjoy life. A little bit slower, a little bit shakier, but everything's okay now. Anyway, I thought that was a great video because it really kind of pulled things together with a lot of the things that we had talked about. All right, so any questions? We've got a few minutes and then we can talk down here if anyone has any additional questions. Thanks, Michael. It was a great little talk. First of all, truncal pain is difficult. It's a dystonic pain. I haven't found it responded well to Botox. Maybe it's just the muscles I was trying to find, the deeper multifidi and the long paraspinals. But I really felt disappointed. I couldn't get a good response out of what appeared to be a dystonic truncal problem in a person with Parkinson's. So I think it's selective. I think what you said was appropriate. And this little video showed it well. And I think we need to understand that. But I do wonder, I think, about the dystonia. As we know, it responds well to botulinum toxins in the neck, for primary dystonias. But this may be of a different animal. The two medications I do find useful in Parkinson's pain was tepentadol because it has a dual mechanism of action, perhaps. On the norepinephrine pathway, which is pre-dopaminergic. And on moderate opiate therapy. So the long-acting tepentadols work, I think, very nicely on that kind of pain. And the other kind of odd opiate that I use for pain is lavorphanol, which has also a unique mechanism. It's more of an NMDA antagonist. And I find it's very useful, especially in geriatrics and with combined spinal problems. So those were two unique meds that I think are often neglected. But I totally agree with a multidisciplinary approach. In our area, the Muhammad Ali Foundation has some boxing programs. Yeah, I've heard that. I agree with you about the tramadol and tepentadol. The combined effects of those two medications, I think you're right. And they seem to be well-tolerated in that age population, too. So I do find them to be very helpful. So that's a good suggestion. Thank you. Very good. It was interesting because they talked about the rigidity, right? It was interesting that they talked about the rigidity. It was interesting that they talked about the rigidity with the DBS, but has there been any intrathecal baclofen studies with that? To go back to your other lecture, because if you're trying the Botox and you're talking about dystonia, it's really nice that he improved with DBS. But to me, if it was a dystonic pain, why not an intrathecal baclofen trial? No, I think that's certainly something to consider. And in some patients, that might be an option to at least give it a try. I can't say that I saw any studies on it, nor have I tried it specifically for that, but I think it's certainly a reasonable consideration. Jenny, I think we're at the 3.30 mark. We'd better let people go. Yeah, well, thank you so much, Dr. Kramer. Those were two very excellent lectures. Thank you.

Parkinson's disease

pain management

dopamine

King's College Parkinson's Disease Pain Scale

deep brain stimulation

multidisciplinary approach

Veterans Administration

levodopa