Resident Physician Johnson Rehabilitation Institute at JFK Medical Center New Brunswick, New Jersey, United States
Case Diagnosis: Symptomatic Parkinson’s Disease
Case Description: A 65 year old male with a past medical history of Parkinson’s Disease (PD) on Sinemet, Rytary and Trihexyphenidyl presented to acute inpatient rehabilitation after elective right knee replacement for primary osteoarthritis. His advanced symptoms include bilateral resting tremor, rigidity, and gait difficulties, all of which severely inhibit his independence and quality of life. During his inpatient stay, his targeted physical and occupational therapies were limited due to orthostatic hypotension (OH), as he was frequently found to have systolic blood pressure in the 70s during transfers or activities focused on mobility. Midodrine, abdominal binders and TED stockings were utilized with limited, although discernible, improvement.
Discussions: Patients with PD who struggle with worsening symptoms such as rigidity, bradykinesia, postural instability and gait difficulties may benefit greatly from inpatient rehabilitation. OH is a common non-motor neurogenic symptom these patients may experience, and it is frequently exacerbated by medications like Sinemet and Rytary. This can cause lightheadedness, syncope, falls, and cognitive impairment, all of which are barriers to rehabilitation. Lifestyle and pharmacologic measures including the use of compression garments and the strategic timing of medications such as midodrine and fludrocortisone should be utilized to allow the greatest opportunity for involvement in rehabilitation. This is significant, as intensive inpatient rehabilitation has been shown to slow the progressive motor decline and provide therapeutic benefits even in advanced PD.
Conclusions: Physiatrists must use clinical judgment when treating diseases, such as continuing necessary anti-parkinson’s medications that may worsen existing OH, hinder progress during therapy and even pose a potential risk. Efforts to limit these side effects are fundamental in the optimization of PD management and the promotion of independence in the safest manner possible.
