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Parkinsons leaflet nm4.indd
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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: email@example.com
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: firstname.lastname@example.org
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Beth M. Silverstein, DONorth Shore University Hospital, North Shore–Long Island Jewish Health System, Manhasset, New York Abstract Effective treatment of epilepsy remains a medical juggling act. Neu- rologists must weigh effective control of seizure activity with patients’ medical histories and comorbidities t