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PTA 120 Pathophysiology Day 15 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 Addison’s Disease Cushing’s Disease Diabetes Mellitus Obesity 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. 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. Pathology for Physical Therapist Assistants, Ch 9 Physical Therapy Clinical Handbook for PTAs Chemical control system Hormonal control though the blood stream Slow acting system Insulin example Hormones control: Reproduction Growth and development Mobilization of body defenses Maintenance of homeostasis Regulation of metabolism On 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. Endocrine Ductless glands Anterior pituitary, thyroid, adrenals, parathyroid Hormones released into blood Exocrine Release products into body’s surface or cavities through ducts Effects of an endocrine disorder may impact physical therapy treatments for another comorbid diagnosis. Description Enlargement of the pituitary gland May start in childhood, usually after puberty; gigantism Adult onset between ages 30 – 50; acromegaly Prevalence of 4676: 1 million in US Etiology Adenomas Overproduction of growth hormone (GH) Presence of tumor causes pituitary to release more GH Signs Dependent upon which cells of the pituitary are affected Children and Symptoms 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) Diabetes, hyperglycemia, hypercalcemia, hypertension, fatigue, impaired vision, headaches, arthritis Treatment Excision of adenoma or pituitary Radiation if parts of adenoma remain Medications to shrink tumor Pituitary hormone replacement therapy For Hyperpituitarism Muscle strengthening and management of arthritis associated with the condition may be necessary. Description Hyperthyroidism = Hyperactivity of the thyroid gland with goiter Metabolic rate can increase by 60-100% Women > men after 20 years of age Named after the Irish Physician Robert J. Graves, 1797 – 1853 Etiology Autoimmune disorder Family predisposition may exist Signs and Symptoms Hand tremors Weight loss Fatigue Hypermobile joints Unusual protrusion of the eyeballs (exophthalmos) Reddening and swelling on the shins and tops of feet (Graves dermopathy) Visible enlargement of the thyroid gland (goiter) Exophthalmos and goiter From Seidel H: Mosby’s guide to physical examination, ed 4, St. Louis, 1999, Mosby. Treatment Decrease thyroid hormone production Control signs and symptoms of the disease Surgery to remove the thyroid Medications – beta-blockers and antithyroidal drugs For 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. 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 Etiology Autoimmune, inherited, iodine deficiency Thyroid is replaced by fibrous tissue -> thyroid shrinks -> reduced thyroid function 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 From Seidel H: Mosby's guide to physical examination, ed 5, St. Louis, 2003, Mosby. For Hypothyroidism Treatment may include strengthening and endurance activities. Description Overproduction of parathyroid hormone (PTH) Women > men 2:1; 100,000 in U.S. annually; increases with age Etiology Primary Secondary From adenoma or hyperplasia of parathyroid -> phosphate reduction Chronic renal insufficiency In response to low levels of calcium / vitamin D Chronic renal insufficiency Tertiary Sharp rise in calcium levels in urine Chronic renal insufficiency Signs Hypercalcemia, hypercalciuria, high level of PTH Renal disease Bone resorption -> pathological fractures -> increased kyphosis and compression fractures of vertebrae Primary and Symptoms Muscle weakness, hypotonic muscles, depression, seizures Secondary Fractures, renal stones from calcium salt build-up, weakness, fatigue, hypertension, constipation, nausea and vomiting, mental changes Treatment Calcimimetic medications Nutrition supplements and dietary changes Surgery to remove parathyroid glands For 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. Description Underproduction of cortisol from adrenal insufficiency Affects females > males, usually between 30 – 50 years of age Etiology Failure of adrenal functions resulting from Autoimmune disease, local or general infection, adrenal cancer, hemorrhage, sudden stoppage of medication Signs and Symptoms General weakness, fatigue, nausea, weight loss, diarrhea, depression, hypotension, possibly cardiac arrest Skin coloration changes Addisonian crisis – acute back, abdomen, or lower extremity pain, severe vomiting, diarrhea, dehydration, hypotension, loss of consciousness Treatment Corticosteroids or aldosterone replacement therapy 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. For 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. 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 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 Treatment Surgery to remove adrenal glands, radiation Possible medications From Seidel H: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby. For 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. 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. 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 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 Signs and Symptoms Occur suddenly and more severely in Type 1; more gradually in Type 2 Glucose in urine Blurred vision Weight loss, increased appetite Nausea, vomiting, abdominal pain Amenorrhea, erectile dysfunction Polyuria, polydipsia, polyphagia Complications Diabetic coma Can result from both hyperglycemia and hypoglycemia Bone disease and long-term effects Osteoporosis Cardiac and vascular diseases Cerebrovascular disease, ischemic changes in the limb, renal disease, reflex sympathetic dystrophy, Dupuytren’s contracture, limited joint mobility, gangrene to extremities Renal disease Eye problems Glaucoma, retinopathy, cataracts Diabetic amyotrophy Reduced function to kidneys Proximal muscle weakness Diabetic neuropathy Foot drop, susceptible to injury due to loss of sensation to the skin, “stocking” or “glove” parasthesias, carpel tunnel syndrome, Charcot’s joint Treatment Insulin injections Medications Dietary changes Weight loss Regular screening of nails, feet, to minimize ulcerations Amputation For 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 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. Description Excess weight > WHO and CDC parameters A goal of Healthy People 2020 is to reduce the number of overweight and obese people Projected that >20% of U.S. population is morbidly obese Etiology Genetics, cultural factors Dietary habits, diet high in fat and protein Sedentary lifestyle Link between adenovirus -36 and -37 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 For 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.