Category: Clinical Sciences/Health Conditions
Case Diagnosis: Idiopathic Parkinson’s
Case Description: 71 y.o. male with history of Parkinson’s Disease (PD) diagnosed in 1997 who presented with increased falls, progressive debility, and severe constipation prompting acute care admission. Hospitalization consisted of multiple complications including recurrent small bowel obstruction s/p resection, encephalopathy, and dysphagia. His acute inpatient rehabilitation was complicated by significant neurogenic orthostatic hypotension (nOH) secondary to autonomic dysfunction (AD). Symptoms restricted therapy with swings in SBP from 200s to 40s at times. Non-pharmacologic measures utilized were abdominal binders, compression stockings, dietary changes, horizontal therapies, and postprandial delay of therapies. Pharmacologic measures included removing aggravating factors, midodrine, rasagiline, salt tabs, and augmenting sinemet. Further implementation of pharmaceuticals continues to be explored including droxidopa.
Discussions: Functional gains were limited by his symptomatic nOH. This resulted in fluctuations of mobility varying between contact guard assist to total assist based on symptoms. Careful team communication was pivotal to address the issues related to the AD. Various pharmacological and non-pharmacological efforts significantly altered his level of symptomatic impairment during therapy. A 2017 JAMA publication demonstrated that early diagnosis of AD in PD patients is an independent risk factor for rapid disease progression and decreased survival time. Given the paucity of reports on rehabilitation outcomes of similar cases, this report aims to present the complex rehabilitation course involved in this disease. It is crucial for the Physiatrist to have multiple treatment options in their “Parkinson’s toolbox” to maximize functional outcomes in this population. Close communication between the Physiatrist, nursing, and rehabilitation team is imperative to further optimize care for this population.
Conclusions: The severity of his nOH is a rare presentation of long standing PD. PD with debilitating nOH presents with therapeutic limitations, significant impact on quality of life, and increased mortality. Optimal care involves a true multidisciplinary approach to assess the multitude of factors involved.
Kevin Ozment– PM&R PGY2 Resident, Northwestern McGaw Medical Center/ Shirley Ryan AbilityLab
Abdihakim Mohamoud– Medical Student, Loyola Stritch School of Medicine
Deena Hassaballa– PM&R/Brain Injury Medicine Attending Physician, Northwestern McGaw Medical Center/Shirley Ryan AbilityLab