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.