Features and exacerbating

factors of low back pain

in Parkinsons disease

Shimohata T1, Watanabe K2, Ishikawa A3Koike R4, Endo N2, Nishizawa M11. Department of Neurology, Brain Research Institute, Niigata University2. Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital3. Department of Neurology, Brain Disease Center Agano Hospital4. Department of Neurology, Nishi-Niigata Chuo National Hospital

Good morning, everyone. Title of my talk is Features and exacerbating factors of low back pain in Parkinsons disease.

The Japanese Society of Neurology (JSN)

COI Disclosure

Name of Lead Presenter T. Shimohata

There are no companies, etc. in a relation of

conflict of interest requiring disclosure in

relation to the presentation.

I have nothing to disclose.

Introduction Among the non-motor symptoms, pain is frequently

observed in patients with PD, and in particular

chronic low back pain (LBP) is very common.

However, the characteristics of LBP, including

its relationships with the various symptoms

or treatments for PD and with musculoskeletal

disorders involving spinal malalignment, have not

been clarified.

First, Id like to give you a brief introduction of our study. Among the non-motor symptoms, pain is frequently observed in patients with PD, and in particular chronic low back pain (LBP) is very common. However, the characteristics of LBP, including its relationships with the various symptoms or treatments for PD and with musculoskeletal disorders involving spinal malalignment, have not been clarified.

Purpose

To determine the clinical features

and exacerbating factors of LBP,

and to evolve strategic points

against the LBP in patients with PD.

The purpose of our study was to determine the clinical features and exacerbating factors of LBP, and to evolve strategic points against the LBP in patients with PD.

Methods We performed a single-hospital prospective

study on 44 consecutive PD patients with LBP.

The clinical characteristics of PD and LBP,

bone mineral density, bone metabolic markers,

spinal alignments, and clinical health status

were evaluated.

This is what we did. We performed a single-hospital prospective study on 44 consecutive PD patients with LBP. The clinical characteristics of PD and LBP, bone mineral densities, bone mineral markers, spinal alignments, and clinical health status were evaluated.

Results

Id like to show what we found.

Neurology

Characteristics of Pts

Treatments for PD

Timing of Sx onset

Triggering factors

From standpoints of Neurology, we investigated characteristics of patients with LBP, treatment for PD, timing of symptom onset, and triggering factors.

Characteristics of patients

Gender 24 male:20 female

Age 69 y.o. (55-85)

Disease duration 11 10 y (1-61)

UPDRS 17 12 (1-56)

This slide shows characteristics of patients. There were 24 male and 20 female patients, with an average age of 69 years. The mean duration of PD was 11 years, and the mean UPDRS score was 17 points.

Modified H & Y stage

This slide shows the modified H&Y stage. As you can see, stages 2, 2.5, 3 and 4 were frequent.

Graph1

2

2

10

13

7

7

3

1

Sheet1

1

S12

S1.52

S210

S2.513

S37

S47

S53

L-dopa equivalent doseMean LED was 498 230 mg0-1267

This slide shows L-dopa equivalent dose. The mean L-dopa equivalent dose was about 500 mg.

Graph1

2

1

0

7

11

7

8

2

1

2

Sheet1

-100-200-300-400-500-600-700-800-900901-

21071178212

Timing of symptoms onset

LBP first 20 patients

PD first 20 patients

Simultaneously 4 patients

Onset age of LBP 55.8 13.9 y.o.

Onset age of PD 57.7 13.7 y.o.

Next, Id like to show the timing of symptoms onset. 20 patients developed LBP first, and 20 patients developed PD first, and remaining 4 patients developed both simultaneously. The mean onset age of LBP was 55.8 years, and the mean onset age of PD was 57.7 years.

Timing of LBP

Constant (23)

Time of waking up

(13)

Afternoon(3)

Evening(4)

None(1)

Timing of the LBP was described as constant in 23 patients, time of waking up in 13, in the afternoon in 3, and in the evening in 4.

Graph1

23

13

3

4

1

Sheet1

23

13

3

4

1

Holding the same position

(19)Daily

activities (11)

Wearing off(5)

Constipation (1)

Walking (9)

Triggering factors of LBP

Triggering factors of LBP were described as holding the same posture in 19 patients, daily activities in 11, walking in 9, wearing-off phenomenon in 5, and constipation in 1.

Graph1

19

11

9

5

1

Sheet1

19

11

9

5

1

Wearing-off phenomenon had a relationship to LBP in 9/21 patients (43%)

Wearing-off

Dyskinesia in 2/8 patients (25%)

Dyskinesia

Medication of anti-parkinsonian drugs relieved LBP in 11/43 patients (26%).

Anti-parkinsonian drugs

Motor complications

With regard to motor complications, the wearing-off phenomenon had a relationship to LBP in 9 out of 21 patients (43%), and dyskinesia in 2 out of 8 patients (25%), and medication of antiparkinsonian drugs relieved LBP in 11 out of 43 patients (26%).

Conclusion 1

The onset age of PD and LBP were contiguous,

and a time period of LBP was mainly described as

constant, or time of waking up.

Exacerbating factors of LBP included modified HY

stage, motor complications of PD, such as the

wearing-off phenomenon and dyskinesia, and

insufficient effects of anti-parkinsonian drugs.

Id like to summarize the first part of our study. The onset age of PD and LBP were contiguous, and a time period of LBP was mainly described as constant, or time of waking up. Exacerbating factors of LBP included modified HY stage, motor complications of PD, such as the wearing-off phenomenon and dyskinesia, and insufficient effects of anti-parkinsonian drugs.

Orthopedic Surgery

Bone mineral densityBone metabolic markers

Spinal alignments

severity of LBP

LBP-related QOL

From standpoints of Orthopedic surgery, we investigated BMD, bone mineral markers, spinal alignments, severity of LBP, and LBP-related QOL.

Bone mineral density

BMD (L-spine) 0.908 g/cm2 (T score -1.0)

BMD (femoral neck) 0.633 g/cm2 (T score -1.5)

BMD measurements demonstrated

osteopenia in the femoral neck.

Bone mineral density measurements demonstrated osteopenia in the femoral neck.

Bone metabolic markersucOC(Undercarboxylated osteocalcin)

6.32 5.74 ng/mL 25(OH)D 53.2 16.0 nmol/L Blood NTX(N-telopeptide)

16.9 6.4 nmolBCE/LUrine NTX 58.6 45.7 nmolBCE/mmolCr

Vitamin K insufficiency(ucOC >4.5 ng/mL)

51%

Vitamin D insufficiency (

Sagittal vertical axis (SVA)

120.2 mm-7326

Lumbar lordosis (T12-S1)-24.0(-5429)

SVA

T12

T5

L2

T10

C7

lumbarlordosis

Spinal alignments

an increased sagittal vertical axis with decreased lumbar lordosis, indicating forward bending of the thoraco-lumbar spine or lower back.

Spinal alignments demonstrated an increased sagittal vertical axis with decreased lumbar lordosis.

forward bending

Lumbar ROM28.7(550)

Flexed position Extended position

Spinal alignments

Lumbar range of motion was also decreased.

Visual analogue scale (VAS)Severe pain

No pain

The mean visual analogue scale (VAS) of LBP, leg pain, and dysesthesia were 5.7, 4.9, and 3.5, respectively.

VAS:100

Graph1

5.7

4.9

3.5

preop

Sheet1

LBPLeg painDysesthesiaSFREMH

preop5.74.93.560.557.548.6

PD-39

Better

WorseAll subscales of the PD-39 demonstrated less than 30 points on average, except mobility which had an average score of 62.4 points.

All subscales of the PD-39 demonstrated less than 30 points on average, except mobility which had an average score of 62.4 points.This finding suggests that LBP caused impairment of QOL related to motor function.

Graph1

62.4

26.2

25.1

18.4

13.1

24.8

19.5

24.3

preop

Sheet1

preopfinalPO2Y

Mobility62.463.566.282

ADL26.272.669.341

Emotion25.160.673.447

Stigma18.458.270.059

Communincation13.160.563.624

Bodily discomfort24.8

Socaila support19.5

Cognition24.3

Conclusion 2

Bone quality demonstrated osteopenia due to

elevated bone resorption, with vitamins K and D

insufficiencies.

Spinal alignments demonstrated that PD patients

with LBP had forward bending of the thoraco-

lumbar spine or lower back.

Id like to summarize the second part of our study. Bone quality demonstrated osteopenia due to elevated bone resorption, with vitamins K and D insufficiencies. Spinal alignment demonstrated that PD patients with LBP had forward bending of the thoraco-lumbar spine or lower back.

Exacerbating factors of

LBP

VAS of LBP

Mobility subscale of the PD-39

Finally, we investigated exacerbating factors using VAS of LBP as well as mobility subscale of the PD-39.

0

2

4

6

8

10

-50 0 50 100 150 200 250 300 350

Sagittal vertical axis (mm)

LBP VAS (point)

0

2

4

6

8

10

-60 -50 -40 -30 -20 -10 0 10 20 30 40

Lumbar lordosis ()

LBP VAS (point)

LBP VAS (point)

Modified H&Y stage

0

2

4

6

8

10

0 5 10 15 20 25 30 35 40 45 50 55

LBP VAS (point)

Lumbar ROM ()

rs=0.314, p

Sagittal vertical axis (mm)

Lumbar lordosis ()

Mobility of the PD

-

39(point)

Modified H&Y stage

Lumbar ROM ()

rs=0.502, p

Conclusion 3

Exacerbating factors of LBP or reduction of QOL

were

(1) PD severity (HY stage)

(2) sagittal malalignment with loss of

lumbar lordosis and decreased lumbar ROM.

Let me summarize final part of our study. Exacerbating factors of LBP or reduction of QOL were (1) PD severity (HY stage)(2) sagittal malalignment with loss of lumbar lordosis and decreased lumbar ROM.

Discussion Because LBP is exacerbated by PD stage and motor

complications, an appropriate regime of anti-parkinsonian

drugs is required.

Because PD patients tend to be underscreened for

osteoporosis, active measures to prevent and treat

osteoporosis should be taken.

Active therapeutic exercises to maintain trunk posture or

lumbar ROM under the direction of a physical therapist is

recommended to treat LBP and improve QOL.

What do these results mean? Because LBP is exacerbated by PD stage and motor complications, an appropriate regime of antiparkinsonian drugs is required. Because PD patients tend to be underscreened for osteoporosis, active measures to prevent and treat osteoporosis should be taken. Active therapeutic exercises to maintain trunk posture or lumbar ROM under the direction of a physical therapist is recommended to treat LBP and improve QOL.

Conclusion The establishment of a partnership between

orthopedic surgeons and neurologists is important to treat LBP.

Exacerbating factors of LBP include stage of motor function and motor complications of PD, stooped posture with decreased lumbar lordosis, and range of lumbar movement.

Therefore, treatment of motor symptoms of PD, treatment for osteoporosis, and therapeutic exercise are important for the treatment of chronic LBP in PD.

Id like finish with some conclusions. The establishment of a partnership between orthopedic surgeons and neurologists is important to treat LBP. Exacerbating factors of LBP include stage of motor function and motor complications of PD, stooped posture with decreased lumbar lordosis, and range of lumbar movement. Therefore, treatment of motor symptoms of PD, treatment for osteoporosis, and therapeutic exercise are important for the treatment of chronic LBP in PD.

Int Orthop. 2015 Dec;39(12):2433-8.

Acknowledgement

This study has already published in the international orthopaedics journal. Thank you for your attention.

1The Japanese Society of Neurology (JSN)COI DisclosureName of Lead Presenter T. Shimohata 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30