ENDOCRINE SYSTEM

PTA 120

Pathophysiology

Day 15

OBJECTIVES Discuss anatomic structures and physiologic

processes related to the endocrine system.

Discuss physical effects of aging on the endocrine system.

Define endocrine pathological conditions including signs and symptoms of each: Hyperpituitarism Hyperthyroidism Hypothyroidism Hyperparathyroidism

OBJECTIVESAddison’s DiseaseCushing’s DiseaseDiabetes MellitusObesity

Discuss how endocrine system pathologies can adversely affect function requiring the modification of treatment intervention to protect the patient from worsening the condition and optimize treatment outcomes.

OBJECTIVES Discuss the modifications and

precautions that may be required for the treatment of patients with disorders of the endocrine system.

Demonstrate understanding of the PTA’s role in the disease processes.

TEXTBOOKS Pathology for Physical Therapist

Assistants, Ch 9

Physical Therapy Clinical Handbook for PTAs

WHY DOES THE PTA NEED TO

KNOW ABOUT THE ANATOMY

AND PHYSIOLOGY OF THE ENDOCRINE

SYSTEM?

THE ENDOCRINE SYSTEM

MAINTAINS HOMEOSTASIS

WITHIN THE BODY. WHEN

THIS IS DISRUPTED, THE

PATIENT’S STRENGTH AND

ENERGY WILL BE ALTERED.

LOCATION OF MAJOR ENDOCRINE ORGANS

FUNCTIONS OF THE ENDOCRINE SYSTEM Chemical control system Hormonal control though the blood

stream Slow acting system Insulin example

Hormones control:ReproductionGrowth and developmentMobilization of body defensesMaintenance of homeostasisRegulation of metabolism

EFFECTS OF AGINGOn the Endocrine System

Physiologic Change Functional Effect

Decreased T3 and T4 production

Decreased metabolic rate

Female ovaries cease to respond to FSH and LH from the pituitary

Stimulates menopause with hot flashes and periodic sweating

Cessation of female ovulation

Reduces hormone levels of estrogen, affects bone density

From: Stillerman (Ed), Modalities for Massage and Bodywork, Elsevier, St Louis, 2008, in press.

GLANDS Endocrine

Ductless glandsAnterior pituitary, thyroid, adrenals,

parathyroidHormones released into blood

ExocrineRelease products into body’s surface or

cavities through ducts

WHY DOES THE PTA NEED TO

KNOW ABOUT DISEASES AND DISORDERS OF

THE ENDOCRINE SYSTEM?

Effects of an endocrine disorder may impact physical therapy

treatments for another comorbid diagnosis.

HYPERPITUITARISM Description

Enlargement of the pituitary glandMay start in childhood, usually after

puberty; gigantismAdult onset between ages 30 – 50;

acromegaly Prevalence of 4676: 1 million in US

HYPERPITUITARISM Etiology

AdenomasOverproduction of growth hormone (GH)

Presence of tumor causes pituitary to release more GH

HYPERPITUITARISM Signs and Symptoms

Dependent upon which cells of the pituitary are affected

Children Longitudinal growth of bones, gigantism Weight gain, failure to grow

Adult Acromegaly = large hands, feet Enlarged jaw, nose, lips, tongue Thickening of facial soft tissues Mood swings Enlargement of internal organs (inc. heart)

HYPERPITUITARISM Diabetes, hyperglycemia, hypercalcemia,

hypertension, fatigue, impaired vision, headaches, arthritis

HYPERPITUITARISM Treatment

Excision of adenoma or pituitaryRadiation if parts of adenoma remainMedications to shrink tumorPituitary hormone replacement therapy

PHYSICAL THERAPY INTERVENTIONFor Hyperpituitarism

Muscle strengthening and management of arthritis associated with the condition may be necessary.

GRAVES’ DISEASE Description

Hyperthyroidism = Hyperactivity of the thyroid gland with goiter

Metabolic rate can increase by 60-100%Women > men after 20 years of ageNamed after the Irish Physician Robert J.

Graves, 1797 – 1853

EtiologyAutoimmune disorderFamily predisposition may exist

GRAVES’ DISEASE Signs and Symptoms

Hand tremors Weight lossFatigueHypermobile jointsUnusual protrusion of the eyeballs

(exophthalmos)Reddening and swelling on the shins and

tops of feet (Graves dermopathy)Visible enlargement of the thyroid gland

(goiter)

GRAVES’ DISEASE Exophthalmos and

goiter

From Seidel H: Mosby’s guide to physical examination, ed 4, St. Louis, 1999, Mosby.

GRAVES’ DISEASE Treatment

Decrease thyroid hormone productionControl signs and symptoms of the diseaseSurgery to remove the thyroidMedications – beta-blockers and

antithyroidal drugs

PHYSICAL THERAPY INTERVENTIONFor Graves’ Disease

A patient with Graves’ Disease may have symptoms including muscle or soft tissue issues. The PTA must be sure not to fatigue the patient and monitor vital signs consistently. Precautions to prevent irradiation due to the patient’s contaminated saliva must be followed.

HYPOTHYROIDISM Description

Underactive thyroid gland leading to deficiency of thyroid hormone secretion in adulthood

Cretinism, Hashimoto’s disease, congenital aplasia, secondary and tertiary

Affects 3% - 5% of population in U.S.; women > men

EtiologyAutoimmune, inherited, iodine deficiencyThyroid is replaced by fibrous tissue ->

thyroid shrinks -> reduced thyroid function

From Seidel H: Mosby's guide to physical examination, ed 5, St. Louis, 2003, Mosby.

HYPOTHYROIDISM Signs and Symptoms

Myxedema (Gull’s disease) = edema, obesity, intolerance to cold, decreased energy

Slowed metabolic rate, slowed mental processes

Muscle weakness Thinning hair or hair loss

Treatment Thyroid hormone

medications

PHYSICAL THERAPY INTERVENTIONFor Hypothyroidism

Treatment may include strengthening and endurance activities.

HYPERPARATHYROIDISM Description

Overproduction of parathyroid hormone (PTH) Women > men 2:1; 100,000 in U.S. annually; increases

with age

Etiology Primary

From adenoma or hyperplasia of parathyroid -> phosphate reduction

Chronic renal insufficiency Secondary

In response to low levels of calcium / vitamin D Chronic renal insufficiency

Tertiary Sharp rise in calcium levels in urine Chronic renal insufficiency

HYPERPARATHYROIDISM Signs and Symptoms

Hypercalcemia, hypercalciuria, high level of PTH

Renal disease Bone resorption -> pathological fractures ->

increased kyphosis and compression fractures of vertebrae

Primary Muscle weakness, hypotonic muscles, depression,

seizures Secondary

Fractures, renal stones from calcium salt build-up, weakness, fatigue, hypertension, constipation, nausea and vomiting, mental changes

HYPERPARATHYROIDISM Treatment

Calcimimetic medicationsNutrition supplements and dietary changesSurgery to remove parathyroid glands

PHYSICAL THERAPY INTERVENTIONFor Hyperparathyroidism

Treatment may include gentle exercise and mobility as well as pain relief and instruction in energy conservation techniques, being careful to avoid fracture or overfatigue.

ADDISON’S DISEASE Description

Underproduction of cortisol from adrenal insufficiency

Affects females > males, usually between 30 – 50 years of age

EtiologyFailure of adrenal functions resulting from

Autoimmune disease, local or general infection, adrenal cancer, hemorrhage, sudden stoppage of medication

ADDISON’S DISEASE Signs and Symptoms

General weakness, fatigue, nausea, weight loss, diarrhea, depression, hypotension, possibly cardiac arrest

Skin coloration changesAddisonian crisis – acute back, abdomen, or

lower extremity pain, severe vomiting, diarrhea, dehydration, hypotension, loss of consciousness

TreatmentCorticosteroids or aldosterone replacement

therapy

ADDISON’S DISEASE

A, from Chew SL, Leslie D: Clinical endocrinology and diabetes: an illustrated colour text, Edinburgh, 2006, Churchill-Livingstone; B, from Forbes CD, Jackson WF: A color atlas and text of clinical medicine, ed 2, St. Louis, 1997, Mosby.

PHYSICAL THERAPY INTERVENTIONFor Addison’s Disease

Adrenal insufficiency may be a comorbid diagnosis for another condition for which physical therapy is indicated. Patients with Addison’s disease may where a medical alert device, and must be monitored carefully.

CUSHING’S DISEASE / SYNDROME Description

Females aged 20 – 60 years Excessive amounts of cortisol in the blood

Hyperpituitarism (Cushing disease) or use of corticosteroids (Cushing syndrome)

Etiology Cushing disease

Pituitary or adrenal tumor stimulating excessive production of ACTH

Cushing syndrome Prolonged or excessive use of high-dose cortisone

drugs Prednisone, dexamethasone, methylprednisolone

CUSHING’S DISEASE / SYNDROME Signs and Symptoms

Abdominal and facial obesity, including “moon face” and “buffalo hump”, hirsutism

Redness of face, thin skin with easy bruising, striae

Hypertension, diabetes, impaired immune system

Osteoporosis, proximal myopathy, fatigue

TreatmentSurgery to remove adrenal glands, radiationPossible medications

CUSHING’S DISEASE / SYNDROME

From Seidel H: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.

PHYSICAL THERAPY INTERVENTIONFor Cushing’s Disease / Syndrome

Treatment may be indicated for the disorders linked to Cushing’s because of the corticosteroid treatments. The PTA should be careful not to harm the skin or joints, and to guard against fractures.

WHY DOES THE PTA NEED TO

KNOW ABOUT DIABETES

MELLITUS?Patients with diabetes mellitus are

frequently seen by PTs and PTAs for either musculoskeletal or wound care issues. It is important for the PTA to

understand the precautions, contraindications, as well as the

indications for the disease.

DIABETES MELLITUS Description

Lack of production of insulin by pancreas; inability of the body to utilize insulin

Type 1 diabetes: insulin dependent Most often seen in children Autoimmune with a genetic component

Type 2 diabetes: non-insulin dependent Most common Most often seen in adults, and in certain ethnic

populations

DIABETES MELLITUS Etiology

Type I Destruction of islet of Langerhans beta cells following an

infection or toxic exposure -> pancreas decreases little to no insulin

Idiopathic or autoimmune with genetic component

Type 2 Resistance to insulin and altered response to glucose ->

hyperglycemia Unknown Risk factors

African- or Asian- Americans, Pacific Islanders, Latin descent

> 45 years of age, sedentary, hypertension, high cholesterol, poor diet, obesity

DIABETES MELLITUS Signs and Symptoms

Occur suddenly and more severely in Type 1; more gradually in Type 2

Glucose in urineBlurred visionWeight loss, increased appetiteNausea, vomiting, abdominal painAmenorrhea, erectile dysfunctionPolyuria, polydipsia, polyphagia

DIABETES MELLITUS Complications and long-term effects

Diabetic coma Can result from both hyperglycemia and

hypoglycemiaBone disease

OsteoporosisCardiac and vascular diseases

Cerebrovascular disease, ischemic changes in the limb, renal disease, reflex sympathetic dystrophy, Dupuytren’s contracture, limited joint mobility, gangrene to extremities

DIABETES MELLITUSRenal disease

Reduced function to kidneysEye problems

Glaucoma, retinopathy, cataractsDiabetic amyotrophy

Proximal muscle weaknessDiabetic neuropathy

Foot drop, susceptible to injury due to loss of sensation to the skin, “stocking” or “glove” parasthesias, carpel tunnel syndrome, Charcot’s joint

DIABETES MELLITUS Treatment

Insulin injectionsMedicationsDietary changesWeight lossRegular screening of nails, feet, to minimize

ulcerationsAmputation

PHYSICAL THERAPY INTERVENTIONFor Diabetes Mellitus

Exercise programs to improve blood pressure, weight loss, decrease heart rate and cholesterol levels, help body utilize insulin

Orthotic assessment, wound care for ulcers Strengthening and lengthening of ankle

musculature Modalities to decrease pain Rehabilitation for amputations Pay particular attention to medication

compliance

WHY DOES THE PTA NEED TO

KNOW ABOUT OBESITY?

Obesity leads to other major health problems. Decreasing obesity is a

focus of attention in the United States, and the PTA is able to influence his

patient’s lifestyle choices such as diet and exercise.

OBESITY Description

Excess weight > WHO and CDC parametersA goal of Healthy People 2020 is to reduce

the number of overweight and obese peopleProjected that >20% of U.S. population is

morbidly obese

EtiologyGenetics, cultural factorsDietary habits, diet high in fat and proteinSedentary lifestyleLink between adenovirus -36 and -37

OBESITY Signs and Symptoms

Relative Weight and Body Mass Index used to measure and classify

Comorbid conditions associated with obesity Cardiovascular disease, type II diabetes, cancer Hypertension, stroke, gallstones, osteoarthritis,

sleep apnea

Treatment Changes in diet and activity level Medications to inhibit absorption of fat Surgery to bypass intestine or reduce stomach

size

PHYSICAL THERAPY INTERVENTIONFor Obesity

Treatment focuses on emphasizing the importance of exercising, as well as giving a high level of encouragement to the obese patient. Education regarding exercise and diet in children, adolescents, and young adults is extremely important.

QUESTIONS