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Parkinson’s Disease and Chronic Pain

Lucie and I are going to do the presentation together, so you’ll be seeing us switch
back and forth a little bit. I’m gonna start just by outlining the objectives for today.
We will start with a quick review about what is Parkinson’s. We understand that most
of you here have a pretty good understanding of that already; but just to make sure we
all have the terminology more or less on an equal field, then we are going to define pain.
What is pain? What are the different types of pain? How are they experienced? And what
is exactly Parkinson’s pain? Then we want to look at different pharmacologic strategies
for reducing pain so, pharmacologic meaning medications mainly. We won’t be spending
too much time talking about any particular drug it’s more the idea of the different
types of medications and things that can be used; and we are going to talk also about
the non-pharmacologic, so, complementary and alternatives ways of addressing the pain and
just before we conclude we’ll talk a little bit about the impact of pain in people living
with Parkinson’s. Lucie:
I don’t think we need to adjust the microphone. All the words are important. The slide here,
you need to know that, of course, just to summarize Parkinson’s, it’s a progressive,
that means it progresses with time, neurological disease, neurodegenerative, the cells in the
brain depleat with time and it is caused by the depletion of dopamine cells in the substantia
nigra. The substantia nigra is a little zone, deep inside the brain, no bigger than an almond
that contains all the dopamine. It is characterized by four things: the acronym for it is TRAP
T for tremor, R for rigidity, A for akinesia, (in this presentation we talk more about bradykinesia
which is the slowness of the movement and akinesia is the absence of movement, in Parkinson’s
we talk more about the slowness of the movement) and P for posture, so change in the posture
with time. These are the motor symptoms of Parkinson’s. This is what your doctor, neurologist
or GP evaluates when he sees you in a clinic. This was first described, in 1817, by James
Parkinson “Essay on shaky palsy”. We’ve been talking about Parkinson’s disease for
a long time. About epidemiology, the quick stats.
In Canada, there is more than 100,000 population in the country.
1% of the population is diagnosed before the age of 65 and 2% over the age of 75.
About 5 to 10 % of patients are diagnosed before the age of 40.
This is very important to me, because it is no longer a senior disease, it is affecting
younger people. When I am in clinic with a mother with young kids in my office, I think
to myself that it could be me instead of her having Parkinson’s. Males are slightly more
affected then female, we don’t know exactly why is that; there is a lot of research there
and it is more prevalent in North America, in Europe then it is in Asia or Africa. It
is everywhere, we’ve been to the Parkinson’s congress in Portland there were 67 different
countries represented by many people. Parkinson’s disease is worldwide. Americans, 1.5 million
with about 60.000 new cases are diagnosed every year. It tends to grow with the aging
of the population. Our goal is not to tell you all about the Parkinson’s medication,
but you already know the different class of medication. Just to summarize, the iceberg
is a famous image we use all the time in conferences. The top of the iceberg are the motor symptoms,
the TRAP I was telling you about (tremor, rigidity, akinesia, bradykinesia and posture)
everything on the surface of water are the motor symptoms, everything under the surface
of water which is always bigger are the non-motor symptoms: problems about sleep, depression,
mood swings, constipation, digestion problems and of course, the pain. We will tell you
all about it in a few minutes. Jennifer:
What is pain? There are so many definitions. Pain is such
a very individual experience that you can’t have one definition that would fit all. The
best I could do, is to say that in medicine, pain relates to sensation that hurts. You
are uncomfortable, and again, the individuality of it can change very much and it only can
be described by the person who is experiencing it. It is very hard for one person to understand
exactly what that sensation of pain feels like to somebody else. It also makes it very
difficult for that person to describe it effectively to their healthcare providers to help us try
to help you. I have included this quote: “My pain has been mainly neurological. I describe
it as like shaking a bottle of fizzy water and keeping the cap on.”
Everybody describes it differently. There is different types of pain: first type is
acute pain is usually very intense but relatively short-lived, meaning 6 months or less and
it usually responds very well to different types of pain medication: Tylenol, Advil maybe
something stronger. Also, acute pain results from injury, whether you have fallen and sprained
your ankle that pain is going to be intense and present, you know exactly why it is there
and you know it has that duration of time, it is not infinite. Another example is incisional
pain, after a surgery you would expect to have pain in the incision site. We won’t
be talking much about acute pain in Parkinson’s because we tend to see more of the chronic
pain. Chronic pain is the opposite of acute, it’s a pain that is being experienced by
someone that is lasting for a period of longer than 6 months, usually much longer, often
the cause is not known it can become difficult to try to isolate the exact reason why this
pain is existing; it can also be very mild it can be sort a of a nagging, dull ache that
is constantly there or it can come in waves of intense pain and then dissipates and then
comes back again. Examples would include: joint pain from arthritis, Parkinson’s pain,
chronic back pain, old sport injury that keeps acting up; all these things can be mixed together
and make it difficult to figure out exactly what the cause is. The cycle of chronic pain
is vicious. The problem with it is when someone is experiencing increased pain, there is an
amount of anxiety that goes along with it: What is this pain from? Is there something
wrong? Will my pain will ever be controlled? Is it going to affect my ability to work?
How am I going to play with my grandchildren, if I can’t get up of the chair because my
back hurts? All that anxiety adds up and tends to make sleeping more difficult. We’ve all
had periods in our lives where we don’t sleep well. When we don’t sleep well, we
don’t cope well, and if you are not coping well, tolerating pain is tougher to do, it
is this constant cycle that turns around, so we want to relieve this pain so that this
cycle can stop. There is many factors that affect how someone experiences pain, one of
them is gender. The research tells us that animals that have
higher levels of testosterone tend to have a higher pain threshold and that animals with
higher œstrogene levels, meaning women, have a lower pain threshold. Personally I think
that this is debatable, we leave that open to discussion. Another factor is family, how
you were brought up will affect how you will experience pain. As a child, you fell and
banged your knee, crying and crying. Your mom and dad would come over and say: “It’s
going to be okay, we’re gonna put some water, some ice, it’s not gonna hurt for long and
it is going to be okay”, you will then experience pain as an adult in a different way than if
you were raised in a family with a very stiff upper lip where you were told “No, no, no,
there is no pain, let’s keep going”, you see how it can mold your experiences as you
become an adult. Culture and ethnicity play a big part as well and a lot of that is overlapping
with family, but there is also the part where in western and explanations in treatment for
pain, we seek more traditional medication, physical therapy and things like that where
is in the eastern and native-american systems they tend to be more open in looking at other
more spiritual and emotional types of healing of pain. How they will cope with pain and
manage it will be influenced differently as well, we need to remember that. There is different
factors that influence pains. Lucie:
Age is one of the main factors. In regards to muscular skeleton pain (MSK),
as we grow older in life, we are perhaps having arthritis, stiff neck, stiff disk, regardless
of Parkinson’s, aging is making us more prone to have some occasional pain. Depression,
there is a strong link in the studies about depression and pain. Of course, if everything
is going well, I feel uplifted and in a good mood; perhaps my knee pain won’t be on the
front burner; on the contrary, if I’m down, if I’m sad, if I have other issues, if I’m
concerned about my children or there is something bad in life, I will probably focus more on
my knee pain, so there is a strong link. Stress, lack of sleep and anxiety are holding with
the pain as well, it can influence terribly the pain that we have. Previous pain experience,
if you have had surgery way back and you remember that you have had a good control of the pain
level or not so good control of the pain level, this will influence what you feel, what you
apprehend about pain. Of course, everyone has a different pain threshold.
What is Parkinson’s pain? It is a non-motor symptom, there is such a
thing as Parkinson’s and pain. Some people say that pain is related to other issues,
it’s no longer true. Experienced by many people with Parkinson’s but not by everyone.
30 to 50 % of the population complains about pain. Not a day goes by without getting calls
about pain, constipation and other things. Pain is on the front burner again. Lack of
standardized tools, what is it out there to help you to be more specific about the pain
when you will talk to us about it. If I reverse the situation, what is it out there for us
to be able to assess your level of pain the best way we can. It’s difficult to explain
the pain, to find the right word, we will teach you to be more specific about it. The
type of pain, its location varies from person to person and because of those many reasons,
you may experience pain in a different way. We need help, you need help to determine the
pain associated with Parkinson’s or with another condition such as arthritis. Parkinson’s
pain is experienced in many different ways again. The first specific pain is called the
dystonia related pain, it is a sustained twisting of a posturing of a muscle group or a body
part; it could be the arms, the thighs, the hands and feet, that are very much painful
for the person who experiences the pain. Dystonia can be caused by both when the Levodopa is
too strong and too weak. So whether the Levodopa is too strong or not enough, you could have
an off-period when the medication is wearing off and all of a sudden you do not have enough
medication, the Parkinson’s symptoms return again. It could bring the twisting of a limb,
a leg or ankle. Could happen with a high dose of Levodopa, let say that you take too much
medication. More rarely, dystonia in Parkinson’s is not caused by the effect of levodopa and
is actually a feature of the condition itself. That’s important. Jennifer:
The second type of pain that we see often in Parkinson’s is called musculoskeletal
pain. That includes muscle cramps, little cramps that you get, not the sustained dystonia
that Lucie was mentioning. The most common type of pain experienced by people with Parkinson’s
and the most common type of pain in people in general. It is usually a discomfort in
muscles and joints the motor features if can sometime be painful and if you are constantly
leaning to one side, the muscles on the other side of your back are constantly being stretched
and pulled, that is going to cause pain over time. The most commonly affected area the
back, the leg, the shoulder tends tmuscles are really achy is that rigidity that is causing
the pain tends to be more localized than some other type and usually gets worse with movement
an aching or stiffness if you ever work out at the gym lifted too heavy of weight, that
feeling that you have when you than certain pain that feeling you have achy what musculoskeletal
pain is. Another type of pain is called akathitic pain, remember the anagram TRAP, A for akinesia/bradynesia
meaning lack of movement in a sense meaning an inability to sit still is the best example
of this type of pain is not always a sharp pain y to describe that its experience inability
to sit still the restless leg syndrome it’s more of a general discomfort people can describe
as almost as ants walking on their skin or this uncomfortable sensation in their legs
that doesn’t get described by you need to move when you move the pain is relieved However
this tends to occur mostly at night, unlike this cartoon, you can’t detach your legs
when you sleep the cycle of chronic pain we know that when you are not sleeping again,
so again… vicious cycle. Neuropathic pain is another type of pain again experienced
in Parkinson’s. Experienced as a numbness tingling heat or intense sensation of cold
that can be felt in the body that can be feel throughout faulty messages to be sent to the
body to the muscles to give that sensation of pain it can be cause by Parkinson’s faulty
wiring it can be cause by Parkinson’s it can also be caused by another changes that
occur with age Degenerative disease those little cushions between your vertebrae and
your spine they lose a bit of fluid the donut turns into a flat tire, you don’t have much
of cushioning anymore that can cause those little nerves that are exiting the spine to
be pinched. A good example for this type of pain. We see it quite often that burning that
burning that goes down the buttock into the leg, this is an example of neuropathic pain.
Central pain, we don’t have much experience about it, to be honest with you, probably
the most alarming pain syndrome in patient with Parkinson’s also one of the rarest
a direct consequence of the Parkinson disease itself, is not the result of dystonia or the
result of musculoskeletal pain or poor posture, really no other cause it is not fully understood
why it is very difficult to treat. People describe it as bizarre unexplained feeling
of stabbing, burning and scalding, tends to travel around the body often presented in
unusual places: abdomen, chest, mouth, rectum or genitalia can be extremely uncomfortable,
the pain can be relentless. How do you know it is Parkinson’s pain or not? That is why
we are here to help you with today, more detailing how to assess and what you can do to help
with the pain. It can be helpful to self-reflect and ask yourself questions even before you
pick up the phone. Is this a new pain? I remember that skiing accident 20 years ago it was the
same place that hurt, it may be relevant, it may be not but, it is worth mentioning
when you call. Have you ever had surgery more detailed even
before you pick up the phone you reflect back it may be relevant it may be not Have I ever
gone to see a doctor about this pain before that might help to ring the bell. Yes, I did
but I don’t remember I’m not sure what it was it helps to see maybe there is a pattern
that you have had this pain before then to see ask yourself could this be an age related
thing more than just my Parkinson’s again it does not mean addressed and treated it
just may help when we’re trying to streamline as to what the cause is. Lucie:
What we want to do is help you to help us to help you with the pain afterwards. Bring
us accurate information. When you come to see the doctor, the patient feels rushed, your moment of glory with your doctor never lasts long. You need to be prepare. It will
help us to direct which angle. One way you can reflect: P Q R S T a straight forward
anagram: P is for provoking factors. What is the cause of the pain. . provoking factors
the pain goes away, Do you notice when it wears off? Is it link with the wearing off
of your medication? The quality of the pain: burning, stabbing what kind of pain is that?
For region and radiation of the pain The stomach. The chest, the genitalia. S, the severity
of the pain on a scale from 1 to 10, what number is it ? When it is at the best, what
number is it? T, the timing of the pain, it is very important because it will trigger
our adjustment for a Parkinson’s medication. Is it worse at a certain time? Is it when
you wake up in the morning? All the questions you need to ask yourself ahead before your
visit to the doctor. Why is it important to be so detailed? It’s optimal for pain management
what we’re trying to achieve here is trying to get rid of that pain. We want specifics.
You can’t fix a leak until you know from where it is coming from. We want to know the
exact cause. A new tool: King’s PD Pain Quest done by the team of a very knowledgeable
neurologist Ray Chadury in the Parkinson field. Yes and no questionnaire the pilot it ourselves
in the clinic. Question no 1: Have you experienced pain around the joints (including pain related
to arthritis)? Question no 4: Have you experienced a non-specific pain deep within the body:
a generalized constant, dull aching pain? You answer yes or no. Generalized pain in
the whole area. This could be completed when you sit in the waiting room to prompt the
discussion with your physician afterward. Generalized pain not affected by muscle groups,
yes or no? 14 questions about the region of the pain. Jennifer:
New tools to help. Different strategies. Once we have identified
the type of pain that is being experienced. It’s unlikely that one treatment would relieve
pain, just like pain itself is complex often the treatment will be complex as well, requires
a lot of time and trial and error and patience. Contributing factors can also make pain relief
more difficult. What might work one day, may not work as well the next day, if you haven’t
slept well, you feel more tired, more stressed, because we know fatigue can impact your perception
of pain. For optimal pain control an interdisciplinary model of care is important, it’s ideal.
Interdisciplinary means that it may not be just the neurologist, plus your family doctor,
plus the nurse, the physical therapist helping with the stretching, maybe go for massages
regularly to help with the muscle tension. Having a team address your pain. Finally,
a combination of both traditional pharmacological approaches and complementary strategies that
offers the best control. Pharmacologic, basically means medication anything a doctor prescribe
to relieve the pain. Break down what can be done with different types of pain. Advil,
Tylenol, or injections of botox into a muscle or nerve blocks into the degeneration of the
discs, topical anesthetics for musculoskeletal pain. Rub a cream or ointment. The non-pharmacologic.
I just want to clarify what is the difference? Alternative is used when people use only alternative
and complementary when they’re combined with another. I am not an expert on all of
them the different things. Managing pain dystonia when medication wears off. This is when you’re
off as the medication is wearing off wave that goes up and down. By looking at the schedule,
marking down , do we need to change the timing? do we change the dose? by adjusting your Is
his is something medication muscles relaxant with hefty side effects. Another sustained
dystonia, if they inject botox, not just for wrinkles, it can actually relax the muscle
and it’s effective for three months. Again, to add on to the dystonia as well, report
benefits elongating the muscles. Yoga, tai chi, meditation. It is not a one shoe fits
all, a matter of trial and error. Lucie:
The musculoskeletal pain comes from the rigidity (R) and the stiffness. Ibuprofen, naproxen.
You need to ask the pharmacist for contrindication with your other medication. The same thing
goes foe acetaminophen depending of your health condition it might be a maximum of 2 grams
per 24 hours. It varies from one patient to another. Topical analgesics, ointment, cream
and we might try to adjust. Other treatments physical and occupational therapy we don’t
acknowledge them enough, these guys are phenomenal, assessment and posture, they give good advice.
Heat and cold, trial and error. Reducing the workload, reducing your stress, the relaxation
will help, biofeedback techniques, acupuncture, acupressure, strengthening I had a back problem
and I started to exercise and my back problem is gone. You are fighting a movement disorder
by being in movement. Akatitic pain: the restless leg syndrome, we are using one class of medication
the dopamine agonists, one dose at night. Mirapex, ropinorole, they come with side effects,
consider pros and cons; sleepiness, nausea, light headedness, that can happen during the
day. We will adjust the levodopa, massage, exercise and cool showers. The neuropathic
pain, sciatica, gabapentin an anticonvulsant with a pain relief effect. The same thing
for the tricyclic antidepressant pain problem has a pain killing effect mechanism, it could
also boost your mood. Amnitro has a pain killing effect and a boosting effect for your mood.
The rationale may increase it and it could have a boosting effect on your mood. It may
increase the neuro transmitter effect in the spinal cord and send a good message to the
brain. The benefits the signal of the pain is reduced. Often it takes four to six weeks,
we ask the patient to be patient. The central pain can be modified by the dopaminergic medication,
we try to adjust, or we will use other medications. Referral to a pain clinic for complex pain;
very long waiting list. Some of you had been referred to a pain clinic and came back disappointed,
the pain is not totally gone, the pain remains, pain that is not treated, they might not want
to see you right away. The complementary and alternative therapies. Jennifer:
The alternative therapies. Heat and cold, relaxation and imagery, simple distraction,
massage, yoga, physical therapy, exercise, acupuncture, psychotherapy and herbal remedies.
Generally, when you have more of an acute type of pain, put cold on it, a cold compress
will help to restrict blood vessels, reduce swelling of the tissue that causes the pain;
it helps to dull the nerve endings momentarily. Heat is better for stiff achy joints, tired
muscles and arthritis. However, there were some conflicting evidence, you do what works
for you: if you have stiff achy joint and putting ice on it makes it feel better, by
all means do the ice. A lot of people find benefits from alternating between both. Heat
and cold. Remember, do not put ice or heat on your skin for more than 20 minutes. Trial
and error, do what’s best for you. The idea is to alternate, it can be done multiple time
during the day because there is no medication involved. Relaxation and guided imagery, a
little bit more challenging, it’s challenging, it works well but it’s a learned process.
Guided imagery is where you hear soothing music, a calm voice telling you that it’s
gonna be okay and guiding you away from the pain and concentrating on your breathing,
it’s bringing you in the moment. DVDs and books. The art of distraction, easiest thing
to do. When you are experiencing pain, if you can identify an activity that you can
do during that time that will help to distract, take your mind off the fact that you’re
having pain. No housework, we don’t enjoy housework; when a pain starts, go and watch
a movie, no scary movie or read a book, listen to music, then it becomes an automatic cue,
it’s complementary and becomes a learned behaviour with time. Massage can really help
promote relaxation, alleviate the perception of pain and anxiety, that increases the blood
flow to source stiff joints and muscles, makes the brain forget about some sensations. This
costs more than watching a movie on TV, massage is beneficial. Some insurances cover massage,
no recommendation on how often or not. Yoga is becoming very popular. Yoga is a mind/
body exercise that combines breath control, meditation and slow fluid movements which
help with stress, stretch and elongate the muscles, increase mobility, no excess wear
and tear on the body when you do it. Shown to be very helpful. Exercise and physical
therapy, we all need to move. We have to keep moving. I feel pain when I move but, you want
me to move more. For example, if you have a sore knee and by not moving, your muscles
get weaker and what the knee needs is a strong muscle below it and above it to help support
the instability. With time, the pain does improve with exercise. Important to consult
a professional to really design a program suited to you. Passive exercise achieves the
same goal. Someone lifts your limbs for you. Acupuncture, insertion of tiny needles in
determined points on the body. The efficiency versus sham. Not a first line therapy I did
have experience in than there is more evidence out there cost involved as with massage. How
often it should be done? After how many sessions you get benefits? The last two: herbal remedies.
Not a lot of evidence in any of these products. Glucosamine. Conflicting reports. Does it
have an impact or not? We need to know what you’re taking to avoid further problems.
Psychotherapy, CBT: cognitive behavioural therapy. Done by a psychologist. It’s talk
therapy with a psychologist. Basically, you relearn how you think and how your body reacts
around pain. The main objective is to increase your activity levels by participating in positive
and rewarding activities. They will encourage you to take up a new hobby, which corrolates
with the distraction part, convincing yourself to do it. The cognitive restructuring part,
this approach helps people identify unhelpful patterns of negative thoughts. When you feel
the pain, you go to your room, lie down and do not come out. We don’t want you to be
isolated, ruminating about your pain. When the pain sets in, get up and do an activity.
It becomes a learned behaviour. Lucie:
What happens when the pain is poorly controlled? What is the effect on our health? It will
worsen our quality of life, decrease your mobility, risk of obesity, muscle atrophy,
depression and you don’t sleep well. Remember the cycle at beginning? It’s really a vicious
cycle. Referral to a pain clinic is not warranted of success. People put all their energy and
their hope in the pain clinic, but pain is a very difficult topic to deal with. The impact
of the pain on the Parkinson’s population, (in 2016, the health care professionals we’re
working with care very much about this matter), it interferes very much with the quality of
life. We want to break the isolation, the withdrawal. We want an impact on the motor
and the non-motor symptoms; pain has an impact on the mood, depression, sleep, poor nutrition,
appetite, functional decline, cognitive process, you are not stimulating yourself, it’s not
what we want. We want to control the pain, we want a good impact on the pain. In conclusion,
people with Parkinson’s know truly that pain exists. It could be link with the disease,
we saw the different types of pain, it could be link to something else and there could
be two different pain problems with the same person. I could have arthritis in my knee
and musculoskeletal pain in my back because of my poor posture. Pain is a multi-dimensional
and complex problem. Highly prevalent, under assessed, under treated. From now on, we’ll
pay more attention to pain. Frankly, some physicians say that we might open a can of
worms. Be prepared. Quality of life will decrease if we don’t take care of the pain. Pain
requires ongoing assessment and modification treatment. If we know about your pain, we’ll
be able to manage your pain better. Speak up be heard!
We can refer you to another specialist: gastroenterologist or urologist.
Thank you very much. Par rapport à la gestion de la douleur, vous
avez mentionné beaucoup de médication, sans mentionner la cortisone; pour un problème
de hernie discale, qui pourrait être associé au Parkinson, que pensez-vous de l’infiltration
de la cortisone? Il y a des injections de cortisone et d’anesthétiques
pour arrêter la douleur; ce traitement n’est pas fait par un neurologue dans une clinique
de troubles du mouvement. On peut vous référer à une clinique de la douleur ou à un orthopédiste.
Eux vont décider si c’est approprié dans votre cas ou non. Une hernie discale n’est
pas un effet directement associé à la maladie de Parkinson mais plutôt relié à l’âge. There was no mention of marijuana as another
form of therapy, would the neurologist consider writing a prescription for a non-pharmacological
product? Very good question. Marijuana is used mainly
for oncology treatment if there is no other way to control the pain. The neurologist will
not hand you a prescription, you need to fill out a form and the specialist will refer his
patient to Medical Marijuana, a medical association and they are the ones who assess the patient
based on the problem. It’s not always ideal, long term use can affect the
cognitive functions, it can be a reason why we don’t go there. How would you differentiate in a situation
of organic discomfort between pain and discomfort whether it’s digestive or not it is not
the type of acute pain that you are referring to?
Use the PQRST. Isolate the problem. If you think it is a gastric or a muscle problem.
Write it in a diary. What time of day is it? What makes the pain worst? Is it a cycle?
Is it pain that goes everywhere? A better answer, in terms of discomfort versus pain,
since discomfort is related to pain, I think that it
is worth mentioning. A greater occurrence of Parkinson’s in the
Americas and Europe as opposed to Africa and Asia, is it environmental notion?
In 2001, I used to say that In 10 years we’ll have a cure. Research is very large, it’s
a multi causal factor. Something in your environment will trigger your Parkinson diagnosis. Research
in different countries and we can’t pinpoint yet, because it is a multi-causal factor. I get terrible pain in the top of my foot,
the doctor said it was inconclusive for arthritis and to go with how the patient feels, this
patient has had enough. The vicious cycle is occurring lately and it is worst at night,
I worry, is it cancer? Think PQRST. What is provoking the pain? What
is the quality of the pain? What region? How severe is it? What is the score from 1 to
10? If you have Parkinson’s, is it always there? Timing is important. What about chiropractors?
Some people do find relief. New pain should be assess first. Start with your family physician
first. Bone alignment, relief. Traditional first. You don’t want to do any damage.
Not much info on it. I’ve been taking my pills with my food,
my pharmacist said so. Now, my doctor tells me to take them before eating. When should
I take it, with or without food? Taking your medication with food to avoid
those queasy, nauseating stomach feelings, to adjust to
the new pills. When the disease progresses, take your pill on an empty stomach, the pill
will be absorbed quicker. Whatever you’re doing, as long as there is no side effects. If
somebody believes he has Parkinson’s, what can expect when a patient receives a Parkinson’s
diagnosis? No specific test to diagnose Parkinson’s.
It is difficult on a first visit. Rule out other causes. They see the tremor. A GP could
suspect that there is Parkinson’s and to confirm the diagnosis is best to see
a neurologist. It may take more than one visit. Over time it gets confirmed. You talked about dystonia, what about dyskenisia?
Are they related? Dyskenisia is involuntary movement, it can
happen twice. When too much medication or when it is wearing off. Muskuloskeletal pain is
not isolated. I have been diagnosed with Parkinson’s 10
years ago. I have no shake, I can’t walk. I am rigid. The right knee area is that right? Two questions. Parkinson’s pain. When I
stand I am off balanced they want me to have a walker, I do not want to. Dizzyness). It depresses me. Am I
right? First question. That’s the reality, we can’t
diagnose your pain. It is a process of elimination. PQRST, what has helped before. Takes patience,
trial and error. Second question. If there is a risk of fall, use a walker. It is you
right to use or not to use the walker. You acknowledge the risk. Thank You

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