Endocrine System

Dr Kaneez Sadia; PT
The University of Faisalabad
Date: 14-11-2018
 Learning objectives
 Normal functions of the endocrine system,
including the thyroid, pituitary, adrenal, and
parathyroid glands, as well as the pancreas
 Clinical evaluation of these endocrine organs
 Endocrine system dysfunction and subsequent
medical management
 Physical therapy guidelines for working with
patients who have endocrine system
dysfunction
 Case study
Patients usually present with non-specific
symptoms of weakness, lethargy, depression,
and mild weight gain Physical examination may
show dry skin, thick tongue, eyelid oedema,
and bradycardia. Elevated TSH and low free
T4.Treatment is levothyroxine at a starting dose
of 1.6 micrograms/kg daily or 25 micrograms
daily in older patients or those with CAD.
What will be the possible diagnosis?
 Case study
• A 55-year-old housewife presented to the emergency
department with complaints of excessive drowsiness,
decreased oral intake and complete inability to open her eyes
for 3 days. In the last three years, she also had difficulty
getting up from the squatting position, combing her hair and
dressing. These difficulties were gradually progressive with no
diurnal variations or periodic fluctuations. She complained of
increased sensitivity to cold, dryness of skin, increased hair
loss, hoarseness of voice and easy fatigability. She had no
history of intake of any prescribed or over-the-counter
medications. She also had no history or family history of any
major illnesses.
 Endocrine System
• The endocrine system consists of endocrine glands,
which secrete hormones into the bloodstream, and
target cells for those hormones.
• Target cells are the principal sites of action for the
endocrine glands.
• The endocrine system has direct effects on cellular
function and metabolism throughout the entire
body, with symptoms of endocrine , metabolic
dysfunction, or both often mimicking those of
muscle fatigue.
Endocrine System
 Screening for Metabolic and Endocrine
Dysfunction
 The following questions help to provide a
systematic method to differentiate the patient's
symptoms and complaints to a specific
endocrine gland.
1. Pituitary
a. Are menses regular? (If they are irregular,
hypo-pituitarism may be suspected.)
b. Has there been a change in vision? (Large
pituitary tumors can result in vision loss.)
 Screening for Metabolic and Endocrine
Dysfunction
2. Adrenal
a. Is there skin darkening? (Chronic primary adrenal
insufficiency results in hyper-pigmentation.)
b. Is there weight loss, nausea, vomiting, or
syncope? (These are suggestive of adrenal
insufficiency.)
c. Have there been episodes of tachycardia,
headaches, and sweating? (These are suggestive
of pheochromocytoma.)
 Screening for Metabolic and Endocrine
Dysfunction
3. Thyroid
a. Is there a change in the patient’s neck size?
(This can indicate the presence of goiter or
hyperthyroidism.)
b. What is the room-temperature preference of
the patient? (60°F suggests hyperthyroidism,
whereas 80°F suggests hypothyroidism.)
 Screening for Metabolic and Endocrine
Dysfunction
4. Parathyroid
a.Is there a history of thyroid surgery? (This is
the usual cause of hypo-parathyroidism.)
b. Are kidney stones, polyuria and constipation
present? (This could indicate hyper-calcemia
from hypo-parathyroidism.)
 Screening for Metabolic and Endocrine
Dysfunction
5. Pancreas
a. Is there nocturia or nocridipsia (urination or
drinking at night, respectively)? (Both of these
can suggest diabetes mellitus.)
b. Has there been a weight loss or gain and
increased appetite? (These also suggest
diabetes.)
General Evaluation of Endocrine Function

• Measurement of endocrine function can be

performed by examining
(1) the endocrine gland itself, using imaging
techniques.
(2) levels of hormones or hormone-related
substances in the bloodstream or urine.
General Evaluation of Endocrine Function

 A common method for assessing levels of

hormone is radioimmunoassay (RIA).
 RIA is an immunologic technique for
comparing levels of radio labeled hormone
with unlabeled hormone, which compete for
binding sites on a given antibody.
Radioimmunoassay (RIA)
 Provocative testing
 Another method of evaluation, referred to as
provocative testing, can be classified into suppcession or
stimulation tests.
 Stimulation tests are used for testing endocrine hypo-
function; suppression tests are useful in evaluating
endocrine hyper-function
 Clinicians should refer to their particular institution's
laboratory values (generally located in the back of the
clinical record) for normal ranges of hormone or
hormone-related substances referenced in their setting.
 Thyroid Gland

• The thyroid is a highly

vascular, brownish-red
gland located anteriorly in
the lower neck .
• The gland formed by 2
elongated lateral lobes
with superior and inferior
poles connected by a
median isthmus, with an
average height of 12-15
mm.
 Thyroid gland function
• The primary function of your thyroid gland is to
secrete thyroid hormones.
• The thyroid hormones are involved in regulating
many of your bodily functions, such as
1. Breathing
2. heart rate
3. Temperature
4. how quickly you burn calories, and digestion
 Thyroid gland hormones
: The 2 main thyroid hormones are

T3 (triiodothyronine)
T4 (thyroxine).

T3 and T4 regulate body's temperature, metabolism

and heart rate.
 T3 or triiodothyronine
T3 tests can help diagnose an overactive thyroid
(hyperthyroidism). The usual accepted normal range
for free T3 (which measures T3 in the bloodstream,
but not T3 bound to protein in your body) is
between 3.1 pmol/L and 6.8 pmol/L
 T4 (thyroxine)
The normal range usually quoted for free thyroxine
(T4) is 12-22 pmol/L. In people with
hyperthyroidism (overactive thyroid), free T4 is
usually above 22 pmol/L. And for those with
hypothyroidism (underactive thyroid), free T4 is
usually below 12 pmol/L.
Thyroid gland hormones
 Thyroid gland disorders
• There are specific kinds of thyroid disorders that
includes:

1.Hypothyroidism
2.Hyperthyroidism
3.Thyroid cancer
 1.Hypothyroidism
• Hypothyroidism refers to any state in which a
person's thyroid hormone production is below
normal.
• There are many disorders that result in
hypothyroidism, for example, autoimmune disorders,
thyroid removal, prescription medications, pituitary
disease, and iodine deficiency.
• Hypothyroidism is a very common condition.
 1.Hypothyroidism
 The symptoms of hypothyroidism include :
1. Increased cholesterol levels
2. Depression
3. Fatigue
4. Hair loss
5. Memory loss
6. Dry rough skin
7. Constipation.
 Management
• Management of neurogenic (hypothalamic or
pituitary dysfunction)
• Dl may consist of pharmacologic treatment,
such as the following: aqueous vasopressin or
deamino-8-D-arginine vasopressin
(Desmopressin), chlorpropamide
• Management of nephrogenic (renal) 01 may
consist of diuretics such as
hydrochlorothiazide
 2.Hyperthyroidism
 Hyperthyroidism is a condition in which there is an
excessive amount of thyroid hormones(GH,ACTH and
ADH).
 Normally, the rate of thyroid hormone production is
controlled by the brain from the pituitary gland, which
is in turn regulated by the hypothalamus.
 Graves' disease, the most common cause of
hyperthyroidism, can be associated with eye disease
(Graves' opthalmopathy)
 2.Hyperthyroidism
 Common symptoms of hyperthyroidism include:
1. Restlessness
2. Agitation
3. Anxiety
4. Tremors
5. Weight loss
6. Sweating
7. Rapid heart rate
Hyperthyroidism
Growth Hormone Overproduction
Signs and symptoms
1. Enlargement of hands and feet, coarse facial features with
furrowed Brows
2. Oligomenorrhea or amenorrhea in women
3. Paresthesia of hands, carpal tunnel syndrome
4. Sweating
5. Headaches
6. lmpotence in men
7. Diabetes mellitus
8. Hypertension
9. Joint pains, osteoarthritis
 Management
• Management of acromegaly may consist of
the following:
• Transphenoid surgical resection of anterior
pituitary adenoma (treatment of choice), GH
suppression with somatostatin
 Adrenocorticotropic Hormone
Overproduction
• Signs and symptoms of Cushing's syndrome include the
following"
1. Truncal obesity with thin extremities
2. Redness and rounding of the face (moon face)
3. Easy bruising, thinning of the skin
4. Oligomenorrhea , or amenorrhea
5. Hypertension
6. Osteoporosis (radiographically confirmed)
7. Proximal muscle weakness
8. Backache
9. Glucose intolerance
 Management
• Management of Cushing's syndrome may
consist of any of the following:
• surgical resection of pituitary lesion, radiation
or chemotherapy for the lesion, or medical
management with steroidogenic inhibitors
(ketoconazole, mitotane, etomidate,
metyrapone, and aminoglutethimide) or
neuromodulators of ACfH release (valproic
acid, bromocriptine, and cyproheptadine).
Antidiuretic Hormone Overproduction
1. Bacterial pneumonias, chronic obstructive
pulmonary disease, tuberculosis, lung abscesses
2. Malignancies of the pancreas, duodenum, colon,
lymphoid tissueand thymus
3. Medication side effects from anti psychotics,
sedative-hypnotics, diuretics, anti-hypertensives,
analgesics, cardiac drugs, and antibiotics Head
trauma, central nervous system neoplasms
 Management of SIADH
• Management of SIADH may consist of any of
the following: treatment of the underlying
cause
1. fluid restriction
2. intravenous administration of sodium
chloride solution, or administration of
diuretics (furosemide)
 3.Thyroid cancer
 Thyroid cancer is three times more common in
women than in men.

 The cause of thyroid cancer is unknown, but certain

risk factors have been identified and include a family
history of goiter and exposure to high levels
of radiation
 3.Thyroid cancer
The most common signs and symptoms of :thyroid
cancer include

1. A lump or thyroid nodule

2. Trouble swallowing
3. Throat or neck pain
4. Swollen lymph nodes in the neck
5. Cough and Vocal changes
 Adrenal and Metabolic Tests
• Evaluation of the adrenal cortical (glucocorricoids,
androgens, and mineralocorticoids) and medullary
(epinephrine and norepinephrine)
• Glucocorticoids can be evaluated by testing serum
and urine cortisol levels, 24-hour urinary
corticosteroids, or ACTH.
• Altered glucocorticoid levels can affect protein and
carbohydrate metabolism.
 Androgens effects in females
• High concentrations of androgens may result
in the following changes in women:
1. Hirsutism
2. Amenorrhea
3. Voice change
4. Increased muscle mass
 Mineralocorticoids
• Mineralocorticoids can be evaluated by testing
serum electrolyte levels or plasma renin
activity and aldosterone levels.
• Abnormalities of serum electrolyte levels,
such as an increased potassium level, provide
a valuable screening tool for mineralocorticoid
secretion disorders.
 Catecholamine
• Epinephrine and norepinephrine are commonly
referred to as catecholamine and their levels are
generally measured through 24-hour
• Urine samples. Dopamine, also a catecholamine, is
the precursor for epinephrine and norepinephrine
and therefore can also be measured
 Metabolic Tests
• Glucose Tolerance Test
 Adrenal Disorders
 Adrenal Insufficiency
 S/S
1. Weakness, fatigue
2. Weight loss, nausea, vomiting, vague abdominal
pain
3. Muscle and joint pain
4. Salt craving in fewer than 20% of patients
5. Hyper-pigmentation
6. Hypotension
 Pheochromocytoma
• Signs and symptoms of pheochromocytoma may
include the following
1. Hypertension (sustained or paroxysmal),
palpitations, tachycardia, and orthostatic
hypotension
2. Headache, palpitations, and diaphoresis
3. Excessive perspiration
4. Nervousness and emotional outbursts or instability
5. Elevated blood glucose levels
 Pancreatic Disorders
• Diabetes Mellitus
1. Diet modification based on caloric content,
proportion of basic nutrients and optimal
sources, and distribution of nutrients in daily
meals.
2. Meal planning.
3. Exercise on a regular basis.
 Diabetic Ketoacidosis
• The following are signs and symptoms of DKA:
1. Polyuria, polydipsia, dehydration
2. Weakness and lethargy
3. Myalgia, hypotonia
4. Headache
5. Anorexia
6. Nausea, vomiting, abdominal pain, acute abdomen
7. Dyspnea, deep and sighing respirations (Kussmaul'
respiration)
8. AcetOne-smelling ("fruity") breath
9. Hypothermia
 Diabetic Dermopathy
• S/S
1. Loss of sensation from sensory neuropathy
2. Skin atrophy from microangiopathy
3. Decreased blood flow from macroangiopathy
4. Sensory and autonomic neuropathy, resulting
in abnormal blood distribution that may
cause bone demineralization and Charcot's
joint (disruption of the mid foot)"
 Foot Care for Patients with Diabetes
Don't
1. Smoke.
2. Wash feet in cold or hot water.
3. Use a heating pad, heating lamp, or
4. hot water bottles to warm the feet.
5. Use razor blades or scissors to cur
corns or calluses.
6. Cross legs when sitting.
7. Wear girdles or garters.
8. Walk barefoot.
9. Wear shoes without socks or
stockings.
10. Wear socks or stocking with raised
seams.
Do
1. Encourage the patient to have regular
2. medical or podiatric examinations to
3. determine integrity of his or her feet.
4. lnspect feet daily for abrasions,
blisters, and curs.
5. Use a mirror if sales cannot be seen. If
vision is poor, another person should
check feet.
6. Wash feet daily with lukewarm water
and soap.
7. Dry feet carefully, especially between
8. the roes.
9. Apply hand cream or lanolin to feet
(dry areas).
10. Be careful not to leave cream between
the toes.
 Physical Therapy Goals
• (1) ro optimize functional mobility, (2) ro maximize activity
• tolerance and endurance, (3) to prevent skin breakdown
in the
• patient with altered sensation (e.g., diabetic neuropathy),
(4) to
• decrease pain (e.g., in patients with osteoporosis or
hyperparathyroidism),
• and (5) to maximize safety for prevention of falls,
especially in
• patients with altered sensation or muscle function.
 Parathyroid Disorders
• Hyperparathyroidism S/S
1. Bone demineralization and resorption (which causes
skeletal changes, such as dorsal kyphosis)
2. Backache, joint and bone pain, and pathologic fractures
3. Kidney stone formation, abdominal pain, and peptic
ulcer disease
4. Nausea, thirst, anorexia, and constipation
5. Hypertension and dysrhythmias
6. Listlessness, depression, and paranoia
7. Decreased neuromuscular excitability
 Hypoparathyroidism
 S/S
1. Hypocalcemia
2. Increased neuromuscular irritability (tetany), painful muscle
spasms
3. Tingling of the fingers
4. Laryngospasm
5. Dysrhythmias
6. Lethargy, personality changes
7. Thin, patchy hair; brittle nails; dry, scaly skin
8. Convulsions
9. Cataracts
 Metabolic Disorders
1. Osteoporosis
2. Osteomalacia
3. Paget's Disease
 Physical Therapy Goals
1. To optimize functional mobility
2. To maximize activity tolerance and endurance
3. to prevent skin breakdown in the patient with
altered sensation (e.g., diabetic neuropathy)
4. To decrease pain (e.g., in patients with
osteoporosis or hyperparathyroidism)
5. To maximize safety for prevention of falls,
especially in patients with altered sensation or
muscle function
 Guidelines
• To improve activity tolerance, it may be necessary to
decrease exercise intensity when the patient's
medication regimen is being adjusted.
• For example, a patient with insufficient thyroid
hormone replacement will fatigue more quickly than
will a patient with adequate thyroid hormone
replacement.
• In this example, knowing the normal values of thyroid
hormone and reviewing the laboratory testshelps the
therapist gauge the appropriate treatment intensity.
 Guidelines
• Consult with the clinical nutritionist to help
determine the appropriate activity level based
on the patient's caloric intake, because caloric
intake and metabolic processes are affected by
endocrine and metabolic disorders.