As a general approach, painful symptoms in PD should be considered in relation to the cardinal symptoms of tremor, rigidity, akinesia, dystonia, and akathisia that occur in PD. It is important to note whether antiparkinsonian medications induce, exacerbate, or relieve PDassociated pain. Most sensory symptoms are worse during "off' motor fluctuations and are considered as nonmotor fluctuations. However, not all pain in the parkinsonian "off' state represents a direct result of dopamine deficiency; for many patients, "off' pain can represent a secondary consequence of increased rigidity and immobility. Pain caused by dystonia can be diagnosed when there is visible twisting, cramping, and posturing of the painful extremity or body part. Dystonia may be painful in the "off' state, but medication-induced dystonia, occurring in the "on" state or during transitions between states, may be painful. Deep brain stimulation may induce painful, dystonic muscle spasms, sometimes attributed to spread of discharge to the corticospinal tract.
A careful appraisal of possible musculoskeletal or rheumatological pain mechanisms is important in patients with Parkinson's disease. Akathisia, while not painful, is intensely unpleasant and is a rare but distinctive symptom that occurs in PD. Primary parkinsonian pain, unrelated to a disturbance in motor function, is presumed to be of cen
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