According to the Parkinson’s Foundation, orthostatic hypotension (OH) affects 15 to 50% of people with Parkinson disease (PWP). The medical definition of orthostatic hypotension is a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing.  Additionally, consideration is taken to the heart rate increase upon standing and if less than 10-15 beats per minute, it may be indicative of OH. 

One of the many lifestyle modifications given is to increase fluid intake.  Increasing fluids for blood pressure management to reduce dizziness, syncope, and fall risk from OH can be very challenging for this population.  Many PWP present with significant self-imposed fluid restrictions as they try to manage common issues with bladder urgency frequency.  Getting ½ their body weight in ounces or the traditional recommendation of 8 glasses a day may feel overwhelming.  A common recommendation from their neurologist or other health care providers is to have 16 ounces of fluid right away in the morning.  Research has shown this to help individuals with autonomic nervous system/baroreflex dysfunction to have rapid symptomatic improvement eliciting a water-induced pressure response and raising their blood pressure.  In PWP with autonomic dysfunction, the baroreceptors, which constrict to increase heart rate and blood pressure upon standing, are sluggish to respond similar to the slowness of movement observed in a PWP.  Individualized and creative daytime urge control techniques, bladder retraining, timed voiding, measured bladder diary assessment, constipation management strategies, and neuromodulation strategies are crucial to maintaining quality of life in coordination with fall safety related to OH.

For those with OH who also struggle with nocturia, the shifting of fluids to earlier in the day may require closer monitoring of blood pressure to ensure our advice is safe.  The Wisconsin Parkinson Association’s director of medical advising and education, Dacy Reimer, APNP, describes the recommended blood pressure tracking methods for reporting back to neurology.  With the use of an electronic blood pressure cuff, blood pressure, pulse, and symptoms can be recorded after sitting for 5 minutes and a second blood pressure after standing for 3 minutes.  This can be regularly tracked once in the morning and once at night.  If we are giving advice for fluid management changes to modify bladder behavior, we may want our patients to monitor this at additional times throughout the day.  Many of my patients who report nocturia at their evaluation, have already tried the common recommendation of stopping fluids 2-3 hours before bed without a change in their symptoms.  A more aggressive fluid shifting plan, where the person will still be asked to get their recommended fluids each day, but achieve that goal much earlier, with a more dramatic tapering at the end of the day has clinically shown benefit.  Trying to fill the bladder more during the day to allow for sensory training/larger fill volumes as well as to flip the circadian rhythm for urine production is the goal.  Monitoring blood pressure as an additional component of the bladder diary, while your patient makes suggested changes, can ensure their safety.   

If additional nuances to the pelvic health complexities involved in Parkinson disease interest you, come delve into it with me even further in my course - Parkinson Disease and Pelvic Rehabilitation scheduled for April 25-26 2025.

Resources:

1. Ramsay, S., & Zagorodnyuk, V. (2023). Role of circadian rhythms and melatonin in bladder function in heath and diseases. Autonomic neuroscience, 246, 103083.
2. Shannon, J. R., Diedrich, A., Biaggioni, I., Tank, J., Robertson, R. M., Robertson, D., & Jordan, J. (2002). Water drinking as a treatment for orthostatic syndromes. The American journal of medicine, 112(5), 355-360.

AUTHOR BIO:
Erica Vitek, MOT, OTR, BCB-PMD, PRPC

Erica Vitek, MOT, OTR, BCB-PMD, PRPC (she/her) graduated with her master’s degree in Occupational Therapy from Concordia University Wisconsin in 2002 and works for Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee, Wisconsin. Erica specializes in female, male, and pediatric evaluation and treatment of the pelvic floor and related bladder, bowel, and sexual health issues. She is board-certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD) and is a Certified Pelvic Rehabilitation Practitioner (PRPC) through Herman and Wallace Pelvic Rehabilitation Institute.

Erica has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman) BIG and is a trained PWR! (Parkinson’s Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica is an LSVT Global faculty member. She instructs both the LSVT BIG training and certification course throughout the nation and online webinars. Erica partners with the Wisconsin Parkinson Association (WPA) as a support group, event presenter, and author in their publication, The Network. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease.

A 2016 study by Kaori et al examined the effect of self administered perineal stimulation for nocturia in elderly women. A prior study using rodents found a soft roller used decreased overactive bladder syndrome (OAB), but a hard roller did not produce the same results. Kaori et al performed a similar study for elderly women in a randomized, placebo controlled, double blind crossover. Participants were 79-89 years old women who applied simulation to perineal skin for 1 minute at bedtime, using either active (soft, sticky elastomer) roller or a placebo (hard polylestrene roller). Participants did a 3-day baseline, followed by 3-day stimulation, then 4 days rest, then other stimuli for 3 days. There were 24 participants, 22 completed the study: 9 with OAB, 13 without OAB. The placement of the roller was not on the skin of the perineal body, but rather on the general peri-anal area with the diagram from the study showing an area just medial to the gluteal crease—where one would find the ischial tuberosity-- and anterior and lateral to the anal sphincter.

Across the subjects with OAB, change with the elastomer roller (soft and sticky feel) was more statistically significant than with the hard roller. Baseline micturition for the participants was 3.2+/- 1.2 times per night, measured as the number of urination between going to bed and arising. The group as a whole did not have a statistically significant difference, measured by at least one less time arising per night. However, in the OAB group, the difference was significant. The researchers theorized that the soft and sticky texture may induce more firing of somatic afferents nerve fibers.

The most commonly prescribed treatment for overactive bladder is anticholinergic therapy, but the side effects, including cognitive changes and lack of significant difference from controls, as well as the drying effect of these drugs in a post-menopausal-low-estrogen-pelvis, bring up questions of whether this is the best option in the elderly.(6)

In anesthetized animals, electrical stimulation and noxious stimuli decrease frequency of bladder contractions when applied to the perineal area (3-5). Somatic, afferent nerve stimuli (those theorized to be active with the soft roller) are used to treat OAB by modalities such as acupuncture and transcutaneous electrical stimulation to the perineum (2). So, stimulation of somatic visceral afferent nerves in the perineal region seems to have an effect on the bladder. However, with manual therapies, it seems we can also affect the somatic or visceral afferents. Essentially, visceral afferents convey information to the central nervous system about local changes in chemical and mechanical environments of a number of organ systems(7). Doing manual therapy between the urethral and bladder fascia would also theoretically cause stimulation of the visceral afferents to the central nervous system about that organ (bladder).

In our pelvic floor intro class (Pelvic Floor Level 1) at Herman Wallace, we discuss the role of Bradley’s neurology loop 3 and the inverse relationship between pelvic floor contraction (lifting the perineal area) and the bladder. One suppression technique we discuss is the contraction of the pelvic floor to quiet or inhibit bladder activity in the bladder retraining program. Bladder retraining has evidence level A (strong) for improving urgency and frequency with overactive bladder.

Clinicians who are ready to raise their manual game may try using the skills of prior series courses and adding the sophistication of manual techniques in the abdomen and pelvis to increase afferent firing in patients with OAB, as well as freeing up any fascial restrictions that may be interfering with full bladder excursion.

In the newly written Capstone course, we combine the prior level of education from the pelvic series (bladder strategies) with manual techniques to address the endopelvic fascia at the bladder base, in the fascial articulations along the perineum, and along its attachments to the coccyx, as well as combining internal work with sacral techniques to facilitate S234 afferents for bladder control. We discuss studies, such as this one, to explore advanced concepts of bladder and urethral fascial mechanics and neural entrapment affecting the bladder. We move out of the pelvic muscle and into the fascial contents of the abdominopelvic region, to allow such firing of the somatic afferents. And the perineal stimulation? We have an entire lab for perineal tissue and its effect on pelvic function. Physical therapists can manually address the perineum, urethral and bladder fascia with Capstone techniques. With such intervention, we get more CNS communication.

So, what about the roller? Well, the soft roller created change in rodents in a couple of studies. (Sato 2010). In this human study, it helped with OAB. Certainly, manual therapies in the region of the endopelvic fascia and suprapubic region may be of help for also stimulating the visceral afferents. Also, it could be worth it to have a high fall risk elderly patient with OAB type nocturia follow up your treatments with one minute of soft washcloth stroking in the area of the perineum for one minute at bedtime to see if it helps decrease the number of voids on a night time bladder diary.

Nari Clemons, PT, PRPC is a Herman & Wallace faculty member who helped author the Pelvic Floor Series Capstone: Advanced Topics in Pelvic Rehab course. She is also the creator and instructor of Pelvic Nerve Manual Assessment and Treatment.

Main study: PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial.Iimura K1,2, Watanabe N2, Masunaga K3, Miyazaki S1,2,4, Hotta H2, Kim H5, Hisajima T1,4, Takahashi H1,4, Kasuya Y3.
2. Exp Ther Med. 2013 Sep;6(3):773-780. Epub 2013 Jul 9., Acupuncture for the treatment of urinary incontinence: A review of randomized controlled trials.Paik SH1, Han SR, Kwon OJ, Ahn YM, Lee BC, Ahn SY.
3. Guo ZF. Transcutaneious electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence. Clin Interv Aging. 2014; 851-6.
4. Sato A, The impact of somatosensory input on autonomic functions. Reve Physiol Biochem Pharmacol. 1997;130;1-328
5. Sato A. Mechanism of the reflex inhibition of micturition conractions of the urinary bladder elicited by acupuncture-like stimulation in anesthetized rats. Neurosci res. 1992 15:189-98
6). Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial. Iimura K, Watanabe N, Masunaga K, Miyazaki S, Hotta H, Kim H, Hisajima T, Takahashi H, Kasuya Y. PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.
7) John C. Longhurst, Liang-Wu Fu, in Primer on the Autonomic Nervous System (Third Edition), 2012