From the Guidelines
Patients with Parkinson's disease experiencing dystonia are at increased risk of stress fractures due to abnormal muscle contractions, postural instability, and bone density issues, and management strategies should prioritize optimizing Parkinson's medication regimens, bone-strengthening medications, and physical therapy to minimize morbidity, mortality, and improve quality of life. The primary risks include fractures in weight-bearing bones (particularly metatarsals, tibia, and femur), delayed healing due to continued dystonic movements, and complications from falls 1.
Risk Factors and Management Strategies
- Abnormal muscle contractions and postural instability increase the risk of stress fractures in patients with Parkinson's disease experiencing dystonia
- Bone density issues, such as osteoporosis, further increase the risk of fractures
- Management strategies should begin with optimizing Parkinson's medication regimens, particularly adjusting levodopa dosing to minimize "off" periods when dystonia worsens
- Deep brain stimulation may be considered for medication-resistant dystonia
- For acute fracture management, immobilization with appropriate casting or bracing is essential, though special attention must be paid to skin integrity due to involuntary movements
- Pharmacological interventions include botulinum toxin injections (50-300 units depending on muscle size) to temporarily reduce dystonic contractions around the fracture site, muscle relaxants such as baclofen (starting at 5mg three times daily, gradually increasing to 20-25mg three times daily as tolerated), and bone-strengthening medications like bisphosphonates (alendronate 70mg weekly) with calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation 1
Long-term Prevention and Monitoring
- Long-term prevention should include regular bone density monitoring, environmental modifications to reduce fall risk, and protective padding in areas of frequent dystonic impact
- Patients with Parkinson's disease experiencing dystonia should undergo regular monitoring of nutritional and vitamin status during the course of the disease, with particular attention to changes in body weight and the need for supplementing vitamin D, folic acid, and vitamin B12 1
- The multidisciplinary approach addressing both the neurological and orthopedic aspects of care is necessary because the abnormal forces from dystonia can complicate standard fracture healing protocols 1
From the Research
Risks of Stress Fractures in Patients with Parkinson's Disease Experiencing Dystonia
- Dystonia in Parkinson's disease can lead to abnormal movements and postures, which may increase the risk of stress fractures 2, 3.
- The abnormal movements and postures associated with dystonia can put excessive stress on bones, particularly in the feet and legs, leading to an increased risk of stress fractures.
- Patients with Parkinson's disease experiencing dystonia may also have impaired balance and coordination, which can increase the risk of falls and subsequent stress fractures.
Management Strategies for Stress Fractures in Patients with Parkinson's Disease Experiencing Dystonia
- Treatment of dystonia in Parkinson's disease can help reduce the risk of stress fractures by minimizing abnormal movements and postures 4, 5.
- Medications such as levodopa, dopamine agonists, and botulinum toxin injections can be used to manage dystonia in Parkinson's disease 4, 2.
- Deep brain stimulation (DBS) can also be an effective treatment option for dystonia in Parkinson's disease, particularly for patients who do not respond to medication 2, 3.
- In addition to treating dystonia, patients with Parkinson's disease should also receive regular exercise and physical therapy to improve balance and coordination, and reduce the risk of falls and stress fractures.
- Continuous dopaminergic stimulation, such as treatment with levodopa-carbidopa intestinal gel, may also be effective in managing severe and troublesome painful dystonia, which can contribute to the risk of stress fractures 6.