Clinical trial NCT03648671: Pain in Parkinson's Disease With Motor Fluctuations.
Official title: Spontaneous and Evoked Pain in Parkinson's Disease With Motor Fluctuations: an Observational, Prospective, Clinical and Neurophysiological Study in Patients Under L-dopa Add on Therapies.
Study type: OBSERVATIONAL
Overall status: UNKNOWN
Conditions: Parkinson Disease
Keywords: Safinamide
Pain
Parkinson
Lead sponsor: Universita di Verona
Sponsor class: OTHER
Collaborators: name: Azienda Ospedaliera Universitaria Integrata Verona
First posted: 2018-08-27
Enrollment: 48
Sex: ALL
Minimum age (years): 18
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: PROBABILITY_SAMPLE
Study population: Males or females patients with mid-to-late PD aged 30 to 80 years with or without chronic pain symptoms (duration \>3 months) and motor fluctuations while receiving L-dopa alone or with other dopaminergic treatments.

Brief summary: Pain (spontaneous pain) is a fundamental non-motor symptom (NMS) of Parkinson's disease (PD) that is prevalent throughout the condition and often unrecognized and undertreated. The study of the scalp laser-evoked potentials (LEPs) (evoked pain) allows a non-invasive exploration of pain central pathways in humans. This technique proved useful in elucidating the physiopathology underlying different pain syndromes. This study has been conceived to study spontaneous pain (and/or evoked pain by laser stimulation) in PD patients (with or without pain) with motor fluctuations under drugs-on (Safinamide Metansolfonato or Rasagilina Mesilato).

Detailed description: Pain (spontaneous pain) is a fundamental non-motor symptom (NMS) of Parkinson's disease (PD) that is prevalent throughout the condition and often unrecognized and undertreated. Different types of pain have been described in association with PD including musculoskeletal, dystonic, central and neuropathic pain. Although musculoskeletal pain is the most commonly reported, a number of patients experience multiple types of pain which are more frequent and disabling in the intermediate phase of disease and which ultimately have a significant negative impact on the patient's quality of life. Despite its relevance, the pathophysiological mechanisms underlying pain in PD are yet to be fully understood. An abnormal nociceptive input processing in the central nervous system leading to hypersensitivity to evoked pain probably underlies all the different pain types experienced by PD patients and also intervene in pain-free PD patients. Additional factors including female gender, depression, disease duration, motor complications, postural abnormalities, medical conditions associated with painful symptoms (osteoporosis, rheumatic or degenerative joint disease,) probably contribute to the quality and distribution of spontaneous pain. Abnormalities in pain processing may be the consequence of decreased basal ganglia dopaminergic neurotransmission, as dopamine has been demonstrated to modulate pain perception in supraspinal regions involved in the pain pathways, including insula, anterior cingulate cortex, thalamus and periaqueductal grey. Furthermore, a neurodegeneration involving non-dopaminergic systems (such as g-aminobutyric acid, glutamate, noradrenaline, and serotonin) that modulate pain processing in other regions of the central nervous systems may also play a relevant role. The variegated pain dimension experienced by PD patients makes its therapeutic management a demanding challenge for clinicians.

The study of the scalp laser-evoked potentials (LEPs) (evoked pain) allows a non-invasive exploration of pain central pathways in humans. This technique proved useful in elucidating the physiopathology underlying different pain syndromes. Some data show that LEPs are altered in PD, in both pain-free PD patients and in PD patients with different kinds of pain, with amplitude reduction in N2/P2 component. Acute levodopa challenge had no effect in normalizing the decreased pain threshold/LEPs observed in PD patients in early Parkinson's disease while in PD patients with motor complications it partially increased pain threshold. This is consistent with the hypothesis that motor complications and pain may share common pathophysiological mechanisms which include not only dopaminergic but also non-dopaminergic systems dysfunction (25).This study has been conceived to study spontaneous pain (and/or evoked pain by laser stimulation) in PD patients (with or without pain) with motor fluctuations under drugs-on (Safinamide Metansolfonato or Rasagilina Mesilato).

Eligibility criteria: Inclusion Criteria:

* PD patients with or without pain willing to participate in this study and able to sign the written informed consent
* To be included in the PD with pain group, the patient's intensity of pain must be moderate to severe over the last month, as reported by a numerical rating scores (NRS≥4) despite the optimal dopaminergic treatment
* No modification of dopaminergic drugs and analgesic therapy with FANS during the 28 days before starting the enrollment in this study.
* Diagnosis of idiopathic PD of ≥3 years duration
* Hoehn and Yahr stage I-III during OFF time
* Motor fluctuations (\>1.5 hours' OFF time/day)
* Patients who would have been treated with add-on therapy irrespective to the present protocol

Exclusion Criteria:

* Patients under (or with previous assumptions) monoamine oxidase inhibitor therapy.
* Late-stage PD experiencing severe, disabling peak-dose or biphasic dyskinesia, or unpredictable or widely swinging symptom fluctuations
* "de novo" patients, patients in early stage or non-fluctuating patients
* Evidence of dementia (MMSE \<24)
* Sign and symptoms suggestive of atypical parkinsonism
* Major psychiatric illnesses
* Severe and progressive medical illnesses
* Concomitant diseases potentially causing acute or chronic pain (i.e., rheumatologic conditions, severe polyneuropathy, and spine injuries)
* Treatments with tri-tetracyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), opioids, neuroleptics, barbiturates and phenothiazines, pregabalin and gabapentin
* Any type of retinopathy

Primary outcomes:
measure: Latency (ms) of N1/P1 complex.
timeFrame: Change from baseline at 12 weeks
measure: Latency (ms) of N2/P2 complex.
timeFrame: Change from baseline at 12 weeks
measure: Amplitude (microvolt) of N1/P1 complex.
timeFrame: Change from baseline at 12 weeks
measure: Amplitude (microvolt) of N2/P2 complex.
timeFrame: Change from baseline at 12 weeks
Secondary outcomes:
measure: Body localization
timeFrame: Change from baseline at 12 weeks
measure: King's Pain Scale for Parkinson's Disease
timeFrame: Change from baseline at 12 weeks
measure: Italian version of the brief pain inventory short form
timeFrame: Change from baseline at 12 weeks
measure: Clinical global impression of change
timeFrame: Change from baseline at 12 weeks
measure: The 39-Item Parkinson's Disease Questionnaire (PDQ-39)
timeFrame: Change from baseline at 12 weeks
measure: Numeric Rating Scale (NRS)
timeFrame: Change from baseline at 12 weeks
measure: Unified Parkinson's Disease Rating Scale
timeFrame: Change from baseline at 12 weeks
measure: Total daily off time
timeFrame: Change from baseline at 12 weeks
measure: Off time following the first morning L-dopa dose
timeFrame: Change from baseline at 12 weeks
measure: Age
timeFrame: One timepoint
measure: Gender
timeFrame: One timepoint
measure: Schooling
timeFrame: One timepoint
measure: Job
timeFrame: One timepoint
measure: Weight
timeFrame: One timepoint
measure: Disease duration
timeFrame: One timepoint
measure: Age at PD onset
timeFrame: One timepoint
measure: Laterality of PD symptom onset
timeFrame: One timepoint
measure: Most Affected Side
timeFrame: One timepoint
measure: Pain symptoms at PD onset
timeFrame: One timepoint
measure: Dominant phenotype
timeFrame: One timepoint
measure: Modified H&Y
timeFrame: One timepoint
measure: Pharmacologic therapy for PD
timeFrame: One timepoint
measure: Comorbilities
timeFrame: One timepoint
measure: Mini-Mental State Examination
timeFrame: One timepoint
measure: Montreal Cognitive Assessment (MoCA)
timeFrame: One timepoint
Other outcomes:
Locations:
city: Verona
country: Italy
facility: Azienda ospedaliera universitaria integrata verona
Study officials:
affiliation: Azienda Ospedaliera Universitaria Integrata Verona
name: Michele Tinazzi, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Defazio G, Berardelli A, Fabbrini G, Martino D, Fincati E, Fiaschi A, Moretto G, Abbruzzese G, Marchese R, Bonuccelli U, Del Dotto P, Barone P, De Vivo E, Albanese A, Antonini A, Canesi M, Lopiano L, Zibetti M, Nappi G, Martignoni E, Lamberti P, Tinazzi M. Pain as a nonmotor symptom of Parkinson disease: evidence from a case-control study. Arch Neurol. 2008 Sep;65(9):1191-4. doi: 10.1001/archneurol.2008.2.
citation: Tinazzi M, Recchia S, Simonetto S, Tamburin S, Defazio G, Fiaschi A, Moretto G, Valeriani M. Muscular pain in Parkinson's disease and nociceptive processing assessed with CO2 laser-evoked potentials. Mov Disord. 2010 Jan 30;25(2):213-20. doi: 10.1002/mds.22932.
citation: Tinazzi M, Recchia S, Simonetto S, Defazio G, Tamburin S, Moretto G, Fiaschi A, Miliucci R, Valeriani M. Hyperalgesia and laser evoked potentials alterations in hemiparkinson: evidence for an abnormal nociceptive processing. J Neurol Sci. 2009 Jan 15;276(1-2):153-8. doi: 10.1016/j.jns.2008.09.023. Epub 2008 Oct 26.
citation: Tinazzi M, Del Vesco C, Defazio G, Fincati E, Smania N, Moretto G, Fiaschi A, Le Pera D, Valeriani M. Abnormal processing of the nociceptive input in Parkinson's disease: a study with CO2 laser evoked potentials. Pain. 2008 May;136(1-2):117-24. doi: 10.1016/j.pain.2007.06.022. Epub 2007 Aug 31.
citation: Zambito-Marsala S, Erro R, Bacchin R, Fornasier A, Fabris F, Lo Cascio C, Ferracci F, Morgante F, Tinazzi M. Abnormal nociceptive processing occurs centrally and not peripherally in pain-free Parkinson disease patients: A study with laser-evoked potentials. Parkinsonism Relat Disord. 2017 Jan;34:43-48. doi: 10.1016/j.parkreldis.2016.10.019. Epub 2016 Oct 24.