such a drop when their system is already under significant stress (e.g., from dehydration), blood pressure may drop to a level that is sufficient to cause a fall. The therapist should assess all individuals with PD for orthostatic hypotension, regardless of whether they have experienced a significant drop in blood pressure. Autonomic dysfunction can also lead to supine hypertension in individuals who have orthostatic hypotension. Supine hypertension is defined as a systolic blood pressure ≥150 mmHg or diastolic blood pressure ≥90 mmHg when lying supine. Although supine hypertension is usually asymptomatic, some patients may complain of a morning headache or a feeling that their head is “full.” When testing for orthostatic hypotension, supine hypertension can be screened for by having the individual lie flat for 5 minutes before taking the supine blood pressure (Asahina et al., 2012). Gastrointestinal problems: Because of changes in the gastrointestinal neural plexus, individuals with PD are prone to constipation. Approximately 50% of those with PD have constipation, and it is often a major problem (Asahina et al., 2012). Constipation can cause discomfort and can negatively impact exercise compliance. Therapists should provide education regarding the benefits of exercise for bowel regularity and the need to consult with a dietician about dietary changes to treat constipation. Urinary problems: Individuals with PD commonly experience urinary problems, primarily those involving incontinence and nocturia (frequent nighttime urination). Although the incidence of urinary problems in individuals with PD is higher than in the general population, the underlying cause may be difficult to determine, because urinary problems are relatively common with aging. Erectile dysfunction is frequently reported in males with PD. Sweating abnormalities: Finally, sweating abnormalities occur in 30 to 50% of individuals with PD. Both hyper- and hypohidrosis can occur in this population. This may be accompanied by heat intolerance. In rare instances, individuals with PD may develop hyperpyrexia syndrome (neuroleptic malignant syndrome), a life- threatening complication that can be triggered by hot weather, infection, or interruption of parkinsonian drug treatment. In hyperpyrexia, the individual develops high body temperature, depressed consciousness, and aggravation of PD symptoms (Asahina et al., 2012). This is a medical emergency and warrants referral for immediate medical attention. Cognitive problems Cognitive impairment is one of the most common and debilitating aspects of PD, affecting 30% of patients with PD (Aarsland et al., 2017). The risk of developing dementia is 3 to 6 times higher in individuals with PD than in individuals of the same age who do not have PD (Aarsland et al., 2017). There is also an increased incidence of mild cognitive impairment in individuals with PD, with up to 20% showing this impairment at the time of diagnosis (Aarsland et al., 2017). The rate of decline in idiopathic PD is initially slow but increases later in the disease process. Dementia in PD presents differently than in AD, with attention and executive function being the areas primarily impacted. Although memory and visuospatial functions can be impaired in PD, they are typically not as predominantly involved as they are in AD (Aarsland et al., 2017). Additionally, verbal fluency is commonly impaired in PD. Problems with attention lead to difficulties in reading and participating in employment activities that require prolonged mental work; executive function deficits lead to difficulties organizing daily life, finances, and work projects. Dual tasking is also negatively impacted by impairments in executive functioning, which leads to difficulty doing two things at once, such as walking and talking or walking and carrying an object. Individuals typically complain of problems with word finding because of verbal fluency issues and exhibit a slowing of speech fluency. Memory problems are noted later in the disease as the dementia progresses. Cognitive symptoms typically present later in the disease; if noted early,
Figure 2: Normal Gait Pattern Compared to Gait Pattern of an Individual with Parkinson’s Disease
The top gait pattern reflects the walking pattern of an older adult with no neurologic diagnosis; notice the longer stride lengths. The bottom gait pattern reflects the walking pattern of an individual with PD. Note . From Western Schools, 2018. 3. Rigidity: Is an increased “stiffness” of the muscles that is not speed dependent. Muscle rigidity affects the proximal musculature early in the progression of PD and subsequently spreads to the muscles of the face and extremities. Two types of rigidity are commonly noted: cogwheel rigidity is a jerky, ratchet-like resistance to passive movement as muscles alternately tense and relax; lead pipe rigidity is a constant uniform resistance to passive movement. Both types of rigidity can lead to muscle shortening, loss of range of motion (ROM), slowness, and fatigue. 4. Postural instability : Includes impaired balance and balance reactions because of damage to the basal ganglia pathways. Deficits in proprioception and sensory integration also play a role in the postural instability of PD (Bzdúšková et al., 2018; Hwang et al., 2016; Ribeiro Artigas et al., 2016). Individuals may have difficulty recovering balance when they are perturbed. They respond to instability with abnormal muscle coactivation patterns. In addition, they exhibit difficulty in feed-forward postural control. Feed-forward postural control is the process of planning for a movement before actually initiating the movement. In feed-forward postural control, muscles are activated to set the posture before moving another part of the body. For example, prior to lifting the arm, the muscles of the back and hip extensors are activated to counteract the forward shift in body mass that is brought on by lifting the arm. The difficulty in feed-forward postural control in PD leads to slowing of movement and/or postural instability. Some individuals with PD exhibit a visually dependent balance strategy, which may be a compensation for proprioceptive impairments. Autonomic problems Damage to the autonomic nervous system leads to problems involving major organ systems such as the cardiovascular, gastrointestinal, and urogenital systems. These autonomic problems are due to changes in cranial nerve X (vagus nerve) and the gastrointestinal neural plexus. It was previously believed that autonomic problems did not occur until late in the progression of PD, but it has become increasingly evident that the nonmotor symptoms caused by problems in the autonomic nervous system are likely to be present before or concurrent with motor symptoms (Poewe et al., 2017). Prescribing a safe exercise program requires that the physical therapist be able to assess for and modify treatment in the presence of autonomic dysfunction. Cardiovascular problems: The most noticeable cardiovascular symptoms result from a decline in the function of the sympathetic system, leading to orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure ≥20 mmHg or in diastolic blood pressure ≥10 mmHg that occurs within 3 minutes of either standing or a head-up tilt to at least 60°. Up to 48% of PD patients exhibit orthostatic hypotension (Poewe et al., 2017). Orthostatic hypotension can result in dizziness and falls and is thought to be one of the major underlying causes of falls in PD. Some individuals can tolerate these drops in blood pressure, but if they experience
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