From the Guidelines
The preliminary workup for bilateral leg pain in a patient with Parkinson's disease should begin with a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1.
Initial Evaluation
The initial evaluation should include a comprehensive vascular examination and inspection of the legs and feet, as patients with Parkinson's disease are at increased risk of peripheral artery disease (PAD) 1.
- A comprehensive medical history should be taken to assess for symptoms such as exertional leg pain, lower extremity rest pain, and lower extremity wounds or other ischemic skin changes.
- A comprehensive vascular examination should be performed regularly to inspect the legs and feet for signs of PAD.
Diagnostic Testing
Diagnostic testing for PAD should be considered, including the resting ankle-brachial index (ABI) as the initial diagnostic test, as recommended by the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1.
- The resting ABI is a simple, noninvasive test that can be used to establish the diagnosis of PAD and institute guideline-directed medical therapy (GDMT).
- Additional physiological testing studies, such as exercise treadmill ABI testing, measurement of the toe-brachial index (TBI), and perfusion assessment measures, may be indicated depending on the clinical presentation and resting ABI values.
Management
Management of bilateral leg pain in a patient with Parkinson's disease should be multifaceted, including optimizing dopaminergic therapy, adding pain medications, and incorporating non-pharmacological approaches.
- Optimizing dopaminergic therapy (levodopa/carbidopa) may help alleviate pain symptoms, particularly during "off" periods when dopaminergic medication effects wear off.
- Adding pain medications like gabapentin or duloxetine may be considered to manage pain symptoms.
- Non-pharmacological approaches, such as heat therapy, massage, and regular exercise, should also be incorporated to manage pain symptoms and improve quality of life.
From the Research
Preliminary Workup for Bilateral Leg Pain with History of Parkinson's
- A thorough assessment of patient history and physical examination should be made in patients with Parkinson's disease to effectively manage chronic pain 2
- The evaluation of leg pain in a patient with Parkinson's disease should include a complete history and physical examination, and may require additional imaging studies 3
- Parkinson's disease patients with bilateral leg pain may experience a specific non-motor phenotype of unexplained lower limb pain, which can be problematic and often undisclosed 4
- Changes in peripheral and central pain processing have been demonstrated in Parkinson's disease patients, and special care in pain assessment is warranted due to the complexity of motor and nonmotor symptoms associated with pain symptoms 5
Potential Causes and Treatment Options
- Unexplained lower limb pain in Parkinson's disease may be a variant of central pain and merits recognition 4
- Treatment options for chronic pain in Parkinson's disease may include dopaminergic agents, acetaminophen, NSAIDs, opioids, antidepressants, physical therapies, and deep brain stimulation 2
- Rehabilitation may represent a valid option to manage pain syndromes in Parkinson's disease, and an integrated approach to pain involving a multidisciplinary team of medical specialists and rehabilitation experts is recommended 5
Diagnostic Considerations
- Dopamine transporter single-photon emission computed tomography can improve the accuracy of diagnosis when the presence of parkinsonism is uncertain 6
- A thorough assessment of patient history and physical examination should be made to exclude co-morbid conditions and determine the etiology of the leg pain 2, 3