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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:
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Hyperpituitarism
Hyperthyroidism
Hypothyroidism
Hyperparathyroidism

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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
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
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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
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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
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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
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Adenomas
Overproduction of growth hormone (GH)
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Presence of tumor causes pituitary to release more GH
 Signs
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Dependent upon which cells of the pituitary are
affected
Children
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and Symptoms
Longitudinal growth of bones, gigantism
Weight gain, failure to grow
Adult
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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
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
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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
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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
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Autoimmune disorder
Family predisposition may exist
 Signs
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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
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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
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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
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Autoimmune, inherited, iodine deficiency
Thyroid is replaced by fibrous tissue -> thyroid
shrinks -> reduced thyroid function
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Signs and Symptoms
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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
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Overproduction of parathyroid hormone (PTH)
Women > men 2:1; 100,000 in U.S. annually; increases
with age
Etiology
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Primary
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Secondary
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From adenoma or hyperplasia of parathyroid -> phosphate
reduction
Chronic renal insufficiency
In response to low levels of calcium / vitamin D
Chronic renal insufficiency
Tertiary
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Sharp rise in calcium levels in urine
Chronic renal insufficiency
 Signs
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Hypercalcemia, hypercalciuria, high level of PTH
Renal disease
Bone resorption -> pathological fractures ->
increased kyphosis and compression fractures of
vertebrae
Primary
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and Symptoms
Muscle weakness, hypotonic muscles, depression,
seizures
Secondary
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Fractures, renal stones from calcium salt build-up,
weakness, fatigue, hypertension, constipation, nausea
and vomiting, mental changes
 Treatment
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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
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Underproduction of cortisol from adrenal
insufficiency
Affects females > males, usually between 30 – 50
years of age
 Etiology
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Failure of adrenal functions resulting from
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Autoimmune disease, local or general infection,
adrenal cancer, hemorrhage, sudden stoppage of
medication
 Signs
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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
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Hyperpituitarism (Cushing disease) or use of
corticosteroids (Cushing syndrome)
Etiology
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Cushing disease
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Pituitary or adrenal tumor stimulating excessive
production of ACTH
Cushing syndrome
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Prolonged or excessive use of high-dose cortisone drugs
 Prednisone, dexamethasone, methylprednisolone
 Signs
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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
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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
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Type 1 diabetes: insulin dependent
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Most often seen in children
Autoimmune with a genetic component
Type 2 diabetes: non-insulin dependent
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Most common
Most often seen in adults, and in certain ethnic
populations

Etiology
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Type I
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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
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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
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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
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Diabetic coma
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Can result from both hyperglycemia and hypoglycemia
Bone disease
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and long-term effects
Osteoporosis
Cardiac and vascular diseases
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Cerebrovascular disease, ischemic changes in the limb,
renal disease, reflex sympathetic dystrophy,
Dupuytren’s contracture, limited joint mobility,
gangrene to extremities
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Renal disease
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Eye problems
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Glaucoma, retinopathy, cataracts
Diabetic amyotrophy
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Reduced function to kidneys
Proximal muscle weakness
Diabetic neuropathy
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Foot drop, susceptible to injury due to loss of
sensation to the skin, “stocking” or “glove”
parasthesias, carpel tunnel syndrome, Charcot’s joint
 Treatment
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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
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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
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Genetics, cultural factors
Dietary habits, diet high in fat and protein
Sedentary lifestyle
Link between adenovirus -36 and -37
 Signs
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and Symptoms
Relative Weight and Body Mass Index used to
measure and classify
Comorbid conditions associated with obesity
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Cardiovascular disease, type II diabetes, cancer
Hypertension, stroke, gallstones, osteoarthritis, sleep
apnea
 Treatment
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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.