Parkinsons leaflet nm4.indd

���������������������������������� � � � � � � � � � � � People with Parkinson’s disease (PD) often fi nd that they are prone to a variety of aches and pains. For example, muscular rigidity and a Information Sheet on Pain in Parkinson’s reduction in, or absence of, movement (akinesia) can lead to cramps, which are often quite distressing and which may not be relieved by ordinary painkillers. Occasionally, people with PD may experience severe muscle spasms or Dystonia in PD is commonly associated with dystonias that are different from ordinary muscle the ‘Wearing Off’ of the effects of levodopa cramps and have different causes and treatments. containing medications (i.e. Sinemet, Madopar or This information sheet aims to describe the Stalevo), in which the drug treatment becomes different types of muscle cramps and dystonias less effective before the next dose of the that may occur in PD and what treatments may be Sinemet, Madopar or Stalevo is due. This effect is known as ‘Off’ dystonia and can often occur in the morning on waking up. A person can experience painful muscular spasms and may Dystonia is a movement disorder characterised be unable to get out of bed until the morning’s by a sustained involuntary contraction of the dose of medication begins to take effect. ‘Off’ muscles causing the affected part of the body to dystonia can sometimes be managed by taking go into spasm. While it can occur as a separate a controlled-release levodopa preparation which condition in itself, referred to as ‘primary’ releases the drug over a four to six-hour period at dystonia, it can also be associated with a number night, but you should discuss this possibility with of other conditions, including Parkinson’s. In such cases, it is often referred to as ‘secondary’ or ‘symptomatic’ dystonia. Dystonia in PD can also be associated with the action of levodopa itself as the medication reaches its peak effectiveness. This is known dystonia can affect anyone and can be prolonged as ‘On’ dystonia and is caused by too much and very painful. The contractions and spasms dopamine in the brain over-stimulating the that are the primary symptoms may lead a person to mistake dystonia for muscle cramps caused by the rigidity found in PD. However, dystonia Finally, dystonia in PD may be unrelated to the and cramping are very different; both make the dose of levodopa and can occur as a feature of muscles hard, but in cramping, muscles become the condition itself. This can happen at any time ‘less elastic’ while in dystonia the hardness comes of the day, but is usually briefer than dystonias from the muscles contracting without relaxing.
Some cramps may respond to vigorous massage Dystonia is usually worse on the side of the body and the application of a heat pad or hot water where the PD symptoms are more pronounced. bottle. Simply moving around may also help, or It can be localised to a single muscle or to a a physiotherapist can advise you on a number group of muscles, but in people with PD it is of stretching exercises that may help relieve most commonly seen in the feet. Spasms in the the stiffness and soreness (see the Parkinson’s calf muscles can cause the toes to curl into a Association’s Information Sheet on Exercise in claw-like position. The foot may also turn in at Parkinson’s Disease for more information). If the ankle and sometimes the big toe can stick up these treatments are not effective, the cramping (hyperextend). This can be very uncomfortable, may respond to drugs such as quinine or muscle especially for people who try to fi t their feet into relaxants (see the section on treatment of tight-fi tting shoes. Although most common in the dystonia later in this information sheet for more feet, dystonia can occur in other parts of the body. details). You should discuss this option with your Other less frequent dystonic effects found in PD often useful for the person with PD or their carer to keep a ‘motor diary’ to determine how the dystonia relates to the timing of the doses. - A spasm of the hand, often provoked by tasks requiring fi ne motor control such as handwriting. People who experience early-morning ‘off’ dystonia For this reason it is known as ‘writer’s cramp’ and may benefi t from taking a controlled-release dose of their medication at night, or from taking their fi rst dose of the day crushed to speed up the effect. - ‘Cervical dystonia’ or ‘spasmodic torticollis’, which is a sustained turning of the head to one side, Your doctor may change your medication regime to bending forward or, more rarely, backward; try to alleviate the dystonia. There are many options available now, from long acting Dopamine Agonists - ‘Blepharospasm’, meaning intermittent or sustained to Enzyme Inhibitors which can allow the levodopa eyelid closure caused by the contraction of the to work more smoothly and affectively, which would eyelid muscles. This can begin in one eye, but will promote continuous delivery of dopamine to the usually continue on to the other eye. Symptoms of this condition include excessive blinking, irritation, a burning sensation in the eyes and photophobia, However, while some people have claimed benefi t an abnormal intolerance to light. These symptoms from these treatment options, not everyone will can be aggravated by stress, looking up or down, For dystonia that does not respond to alterations - ‘Spasmodic dysphonia’ or a spasm of the vocal in the Parkinson’s drug regime, a number of other drug treatments are available. These include muscle relaxants or benzodiazepines such as diazepam - Hemimasticatory or hemifacial spasm, a spasm (Valium) and clonazepam (Rivotril), Baclofen (Lioresal), affecting one side of the jaw area or one side of the and anticholinergics such as biperiden (Akineton).
A doctor may also be able to advise on the addition of other medications, such as muscle relaxants at Dystonias may be treated by a variety of physical bedtime, or injections of botulinum toxin (Botox, treatments, by changes to medications or surgery. Dysport or NeuroBloc) into the affected area of the Further information on these treatments is provided body. Botulinum toxin is a powerful nerve toxin (or poison) that is sometimes used to treat dystonia. Used in small doses in a purifi ed form, botulinum toxin is injected into the affected muscles and blocks As some ordinary muscle cramps can respond well to the release of the chemical messenger acetylcholine. simple techniques such as massage, moving around or Blocking this release prevents the nerves from heat, some people fi nd temporary relief from dystonic signalling the muscles to contract. As a result, the spasms by using ‘sensory tricks’. These usually mean injected muscles are weakened and the spasms touching the affected body part before or while caused by dystonia are lessened. This treatment making a movement known to trigger a dystonic needs to be repeated every three to four months.
spasm. This appears to inhibit or shorten the spasm by giving the brain a distracting sensation to process or Any change in your drug regime or the addition of extra medications must be discussed thoroughly with your doctor or Parkinson’s specialist. Drug Other techniques may be used – spasmodic dysphonia regimens in PD are highly individual and some of the in the vocal cords, for example, can sometimes be treatments listed here may not be appropriate. Your doctor will be able to discuss possible treatments in relation to your own circumstances.
Some people with blepharospasm in the eyes have found relief in talking, lying down, singing, yawning, laughing, chewing or putting pressure on the Surgery for dystonia is not common, but may be considered in some cases where a person is not responding to drug treatment. Surgical procedures such as thalamotomy, pallidotomy, and deep brain The fi rst step is to identify the underlying cause. In stimulation already used for PD have also been found PD, levodopa-related dystonias should respond to to be benefi cial for dystonia. You should discuss this alterations in the type or timing of the regimen. It is AcknowledgementsParkinson’s Association of Ireland would like to thank Parkinson’s UK for permission to use PDS Leafl et FS43 as the basis for this Information Sheet.
Also, our thanks to Dr. Fiona Molly, Consultant Neurologist in Beaumont Hospital, Dublin, for endorsing this Leafl et.
Further informationDystonia Ireland offers support to all people with dystonia and has a range of information on the different forms of the condition and the treatments available. Dystonia Ireland can be contacted at:Dystonia Ireland, 33 Larkfi eld Grove, Harold’s Cross, Dublin 6WTelephone: 00353 (0)1 492 2514 • Fax: 00353 (0)1 492 2565E-mail: info@dystonia.ie Other Relevant Information SheetsNM5: Pain in Parkinson’sEX1: Exercise in Parkinson’sG4: Medications and Parkinson’s Disease DISCLAIMER – The information on these pages is not intended to be taken as advice. No changes to your treatment should be made without prior consultation with your doctor or allied health professional. National Offi ce: Carmichael House, North Brunswick Street, Dublin 7, Ireland. Tel: 00 353 1 872 2234 Fax: 00 353 1 872 5540 Parkinson’s Association of Ireland is a registered charity with limited liability. Company Reg. No. 123532. Charity Reg. No.CHY 10816. Registered address as shown National Freephone Helpline 1 800 359 359 9 am – 9 pm weekdays www.parkinsons.ie Email: info@parkinsons.ie

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