Endocrine, Metabolic, and GI Systems

endocrine system

network of various glands that synthesize & release hormones, which travel thru the bld to cells & organs for regulation

5 functions of the endocrine system

1. differentiation of reproductive & CNS of developing fetus

2. stim of sequential growth & development during childhood & adolescence

3. coordination of malee & female reproductive systems

4. maintenance of optimal intl environment thruought the lifespan

5. irritation of corrrective & adaptive responses when emergency demands occur

endocrine patholgoy may be due to ___ or ___ in the hypothalamus, pituitary, or other glands

inflammation; tumor

anatomic changes of the endocrine glands due to age

pituitary: decr weight by 80 y/o, decr bld flow

thyroid: gland shrinks, fibrosis

parathyroid: gland shrinks, fibrosis, no change in PTH levels

adrenals: fibrosis, no change in cortisol levels

reproductive glands: physiological effects on cardiovascular & skeletal systems

hormonal changes of the endocrine system due to age

menopause in women, decr GH

endocrine dysfunction NMS s/s

proximal muscle weakness, atrophy, myalgia, fatigue that doesn’t go away w/ rest, rheumatic-like s/s (joint pain), carpal tunnel, synovial fluid changes, DM, spondyloarthropathy, OA, osteoporosis, osteonecrosis, hand stiffness, pseudogout

endocrine dysfunction systemic s/s

excessive/delayed growth, polydipsia, polyuria, mental changes (nervousness, confusion, depression); changes in hair, skin pigmentation, body fat fistribution, VSs (elevated temp, pulse, BP); heart palpitations, incr perspiration, dehydration/excessive retention of body water, Kussmaul respirations (deep rpid breathing)

always be on alert for pts w/ bilat ___ ___, atypical ___, or adhesive capsulitis (DM)

carpal tunnel; RA

ant lobe of pituitary gland (adenohypophysis)

produces & releases hormones (GH, ACTH, TSH, FSH, LH, PRL); most affected by pituitary disorders

post lobe of pituitary gland (neurophypophysis)

stores & releases hormones (ADH, oxytocin from hypothalamus)

hyperpituitarism

oversecretion of 1+ hormones typically caused by benign tumors (pituitary adenoma) → excessive GH (acromegaly, gigantism), ACTH (Cushing disease), TSH (hyperthyroidism), PRL (amenorrhea/galactorrhea/gynecomstia)

pituitary tumors will also produce symptoms as they expand w/n the skull, such as…

visual field abnormalities, headaches, somnolence

hypopituitarism

undersecretion of 1+ hormones typically caused by hypophysectomy, nonsecreting pituitary tumors, postpartum hemorrhage, reversible functional disorders (starvation, anorexia, severe anemia, GI disorders) → insufficient GH (dwarfism), ACTH (hypoglycemia, anorexia, nausea, abdominal pain), TSH (fatigue, lethargy, cold sensitivity, menstrual disturbance), gonadal failure (2ndary amenorrhea, impotence, infertility, decr libido, absent 2ndary sex characteristics in children)

gigantism

enlarged tumor in normal tissue → hypersecr of GH → abrupt overgrowth of long bones before epiphyseal plates close → up to 9 ft height, incr IGF-1 & mortality, decr conscious/viscual acuitty, falling PR, rising BP, meningitis s/s

treatment: hypophysectomy, drugs, radiation, decr QOL, no coughing/sneezing/nose blowing

acromegaly

enlarged tumor in normal tissue → hypersecr of GH → slow incr bone thickness, soft tissue hypertrophy after epiphyseal plates close → coarse facial features & pronathism (thick ears, nose, tongue, hands), headache, diplopia, blindness, lethargy, myopathy, decr exercise tolerance, OA, chondrocalcinosis, CTS, backpain, incr mortality, weakness, change in ROM

treatment: decr QOL, hypophysectomy, drugs (statins for joint pain), radiation

orthopedic considerations of acromegaly

arthritis in hands & spine, osteophytes/bone spurs & incr joint space from thick cartilage, stenosis & chondrocalcinosis, bilat CTS, back pain (large osteophytes along ALL)

role of PT for acromegaly

joint mobilization, soft tissue ROM, muscle strengthening, functional skills & ADL training

thyroid gland

secretes hormones that act on nearly all body tissues, affecting multiple systems (nails, hair, skin, eyes, GI, respiratory, heart, bld vessels, nerves, bone, muscle; regulated by hypothalamus-pituitary feedback controls, intrinsic regulator

EX: thyroxine (T4), triiodothyronine (T3), calcitonin

hypothalamus-pituitary feedback

positive feedback where hypothalamus senses decr T3 & T4 → release TRH → tells pituitary to send TSH to thyroid → release more T3 & T4

negative feedback where hypothalamus senses incr T3 & T4 → tells ant pituitary to decr TSH & hypothalamus to decr TRH

hyperthyroidism

hypersec of thyroid hormones (thyrotoxicosis) → incr body metabolism → goiter → Grave’s disease → thyroid storm → CNS (tremors, hyperkinesis, nervousness, emotional lability, weakness/atrophy, incr DTR, fatigue), CV (tachycardia, palpitations, arrhythmias, weak respiratory muscles, low BP, HF), MS (weakness, fatigue, atrophy, chronic periarthritis, myasthenias gravis), integumentary (capillary dilation, heat intolerance, nail changes, hair loss), ocular (exophthalmos, eye muscle weakness, light sensitivity, lid tremor), GI (weight loss w/ incr appetite, incr peristalsis, N/V/D, dysphagia), GU (polyuria, amenorrhea, femaile infertility) s/s

treatment: antithyroid meds if under 18 y/o, radioactive iodine, surgery, prognosis is good but requires lifelong folowup after remission

goiter

lack of iodine → accumulation of thyroglobulin → enlargment of thyroid, inflammation, tumors → pressure on trachea, esophagus → dyspnea, dysphagia, hoarseness, carotid a. occlusion; usually in developping countries where iodine is deficient in diet but prevented w/ iodized salt in US/Canada

type 1 hyperthyroidism

hormone deficient

type 2 hyperthyroidism

homone resistant

Grave’s disease

hyperthyroidism autoimmune disease that incr T4 production; affects women more than men (4:1) b/n 20-40 y/o

thyroid storm

potentially fatal hyperthyroidism → high fever, severe tachycardia, delirium, dehydration, AMS

hypothyroidism

undersecr of thyroid hormones → slow body metabolism, pseudogout (early) → CNS (slow speech, hoarseness, slow mental functions, fatigue, headache, cerebellar ataxia, anxiety, depression), CV (bradycardia, CHF, poor peripheral circulation/pale/cold skin, cold intolerance, HTN, severe atherosclerosis, angina, incr BP, cardiomyopathy), MS (prox weakness, myalgia, trigger points, stiffness, CTS, decr DTR, edema, back pain, incr bone density, decr bone formation/resorption), integumentary (myxedema, thick/cool/dry/scaly skin, carotenosis, thin hair, cold intolerance, edema, poor healing), hematologic (anemia, easy bruising), GI (anorexia, constipation, weight gain, poor protein metabolism, delated glucose uptake), GU (infertility, menstrual irregularity, menorrhagia), respiratory (dyspnea, respiratory muscle weakness) systems s/s

treatment: synthetic thyroid hormone, good prognosis

type 1 hypothyroidism

hormone deficient, 95% of ppl, TSH elevated

type 2 hypothyroidism

hormone resistant; usually pituitary problem, low TSH

PT role in hypothyroidism

caution w/ manual techniques bc of fragile skin, poor exercise tolerance bc of cardiac s/s & thyroid hormone dosage (should start low & slow)

Hashimoto’s thyroiditis

genetic autoimmune disease → thyroid gland destruction bc of lymphocytes & antithyroid antibodies → TSH elevation → painless, symmetric/asymmetric goiter → pressure on surrounding structures; affects women 10x more frequently than men at 30-50 y/o

treatment: meds to suppress TSH

adrenal cortex & medulla are major players in the body’s response to ___

stress

adrenal cortex

outer adrenal glands that secrete mineralocorticoids (aldosterone), glucocorticoids (cortisol), androgens (sex hormones)

adrenal medulla

inner adrenal glands derived from neural tissue that secrete epinephrine & norepinephrine → vascular tone, heart, nervous system, glucose metabolism

adrenal primary insufficiency/Addison’s disease

acute/chronic disorder of insufficient cortisol & aldosterone → hypoglycemia, liver glycogen deficiency, anorexia, N/V, depression, bronzed/tanned skin (naturally light skin) or slate grey skin (naturally darker skin) on extensor surfaces, hypotension, dehydration, decr CO, arrhythmias & hypokalemia, cardiac arrest, poor coordination, poor exercise tolerance initially; uncommon but more in women more than men at 40-60 y/o, surgery, pergnancy, trauma, infection

treatment: replace fluids, electrolytes, glucose, cortisol; synthetic corticosteroids & mineralcorticoids; can be fatal if untreated

___ therapy is a contraindication for Addison’s disease/primary adrenal primary insufficiency due to…

aquatic; demand for cortisol (water affects diffusion of electrolytes), steroid-induced psychosis bc of synthetic meds

secondary adrenal insufficiency

hypothalamic/pituitary tumors, hypophysectomy, hypopituitarism, rapid corticosteroid w/drawal, long-term exogenous use of corticosteroids → insufficient cortisol & aldosterone → athralgias, myalgias, tendon calcification

treatment: synthetic corticosteroids & mineralocorticoids

adrenocortical hyperfunction

hypersecr of glucocorticoids, mineralocorticoids, androgens → persistent hyperglycemia (steroid diabetes), protein tissue wasting (weakness, fragile capillaries, osteoporosis), K+ depletion (hypokalemia, arrhythmias, renal disorders), Na/H2O retention (edema), HTN (L ventricular hypertrophy, CHF, CVA), abnormal fat distribution (moon face, Buffalo hump, stretch marks), incr infection risk & poor wound healing, incr androgen production (hirsutism, acne), mental changes (memory loss, poor concentration, depression,steroid psychosis)

EX: Cushing syndrome (excess gluco), Conn syndrome/aldosteronism (excess aldosterone), adrenal hyperplasia (androgenital syndrome)

treatment: restore hormone balance, pituitary irradiation, drug therapy, surgery, high-protein diet, lifelong glucosteroid replacement, prognosis dependent on cortisol levels control

obesity

multifactorial disease w/ complex interactions b/n lifestyle (sedentary, hyperglycemic diet), environment (hx of sexual abuse, socioeconomic status, EDs, lack of sleep, stress), and genetics (hypothyroidism, PCOS, Prader-Willi Syndrome) → imbalance b/n energy intake/expenditure → excessive accumulation of fat in the body → metabolic syndrome, type 2 DM, liver diseases, OA, sleep apnea, atherosclerosis, HTN, stroke, asthma, cancer, menstrual disorders, infertility, lymphedema, impair mobility, premature death; most significant contributor to ill health & preventable death, 2nd to smoking, numerous chronic diseases, early mortality, early morbidity

treatment: weight loss, meds, surgery, behavior/lifestyle changes, good prognosis w/ significant lifestyle changes

BMI & classification

current gold standard measurement for obesity but can be inaccurate; obesity measurement shifting towards waist circumference or waist-to-hip ratio

overweight, incr risk of death & disability BMI >/25

obese BMI >/ 30

adipose cell theory

some ppl have inherently excessive fat cells (hyperplasia) & larger fat cells (hypertrophy)

microbial theory

intestinal microorganisms → incr fat retention

metabolic syndrome

must have all characteristics

abdominal adiposity (waist >40 in men or >35 in women), high triglycerides (>150 mg/dL), low HDLs (<40 in men or <50 in women), high bld sugar (>100 mg/dL), high BP (>130/85 mmHg)

preventions for obesity

physical activity, nutrition education, positive social environments

PT role in treating obesity

primary prevention (appropriate energy balance to avoid weight gain), 2ndary prevention (decr severity/duration of existing conditions), and tertiary prevention (limit sequential chronic health conditions)

potential exercise consequences for pts w/ obesity

angina pectoris/MI, excessive incr in BP, aggravation of degenerative arthritis, ligamentous injuries, falls injury, excessive sweating, skin disorders, chafing, hypohydration, decr bld circulation, heat stroke/exhaustion

PT considerations for pts w/ obesity

pt education on body composition b/n adipose & muscle mass; back pain, joint pain (knee & hand); mobility/balance in single-leg stance, physical activity/ambulation difficulty, post-op complications (respiratory, integumentary, cardio), post-bariatric surgery (vitamin & mineral deficiencies → change in wound healing, neuro s/s)

diabetes mellitus (DM)

group of endocrine/metabolic diseases from defects in insulin secr, action, high cortisol/stress, lack of sleep, depression, FMHx → chronic systemic disorder of hyperglycemia → disruption of metabolism of carbs, fats, proteins → long-term damage to eyes, kidneys, nerves, heart, bld vessels; leading cause of blindness & renal failure in adults; common in non-white Americans (90% = type 2, 10% = type 1)

type 1 DM

hyperglycemic cell-mediated autoimmune destruction of beta cells → decr insulin, decr utilization of glucose, incr fat mobilization, impaired protein utilization → polyuria, polydipsia, polyphagia, weight loss, recurrent blurred vision, ketonuria, weakness, fatigue, dizziness; evidence of autoimmune process in the islet cells & genetic markers; prone to ketoacidosis; requires eogenous insulin; less common than type 2 DM

type 2 DM

hyperglycemic condition of difficulty utilizing insulin, meds preventing hyperglycemia, obesity, sedentarism, >45 y/o, hx of gestational diabetes, PCOS, hx of vascular disease, HTN, smoking → combo of cellular insulin resistance & inadequate insulin secr → polyuria, polydipsia, recurrent blurred vision, weakness, fatigue, dizziness; often asymptomatic; control w/ diet, exercise, oral hypoglycemic agents

glucose regulation glands

pancreas/islets of langerhand: glucagon, insulin, somatostatin, polypeptide

adrenal gland: epinephrine (stims glycogenolysis to incr bld glucose), glucocorticoids (incr bld glucose by sending AAs to liver)

ant pituitary: ACTH (incr bld glucose) & GH (limits fat storage, favors fat catabolism, incr glucose)

thyroid: T3 & T4 incr/decr bld glucose levels

hypoglycemia onset & mood

rapid; labile, irritable, nervous, weepy

hyperglycemia onset & mood

gradual; lethargic (slow, lacking energy)

complications of diabetes

hyperglycemia, fat accumulation, hyperostosis in spine, arthritis, osteoporosis, pressure injuries, cognitive decline, macrovascular (accelerated atherosclerosis), microvascular (retina blindness, glomerular kidney failure, vasa nervorum neuropathy)

diagnosis of diabetes

fasting plasma glucose test, oral glucose tolerance test, hemoglobin A1C test, s/s of hyperglycemia, blood/urine glucose, ketone abnormalities

casual [plasma glucose] >/ 200 mg/dL, fasting plasma glucose (FPG) >/126 mg/dL after no caloric intake for 8+ hours, 2-hour post-load glucose >/ 200 mg/dL during oral glucose tolerance test, A1C >/ 6.5%

PT considerations for pts w/ diabetes

glucose before & after exercise, high incidence of injuries, resistance exercise has the biggest effect on glycemic control, hypoglycemia s/s (pale, sweaty, goosebumps, tachycardic, palpitations, nervousness, weakness, sakiness, hunger, headache, blurred vision, slurred speech, numbness, confusion), worsening hyperglycemia, MI, arrhythmia, excessive rise in BP during exercise, post-exercise orthostasis, retinal hemorrhage or incr proteinuria, degenerative joint disease, orthopedic neuropathy injury

pts can have symptoms of hypoclycemia when glucose ___ quickly, even if the level is still elevated → keep easy administration of ___

drops; sugar

metabolism

physical & chemical processes that allow cells to utilize food to continually rebuild body cells & transform food into energy; anabolic (tissue-building) & catabolic (energy-producing) phases

osteoporosis

signs of decr bone density (osteopenia) → chronic, progressive disease characterized by low bone mass, impaired bone quality, decr bone strength, enhanced risk of fractures, loss of height, severe kyphosis, back pain, vertebral compression fx; common metabolic bone disease; incidence incr as life expectancy incr; common in postmenopausal women (estrogen deficiency), 50+ y/o, caucasion/asian, north european ancestry, prolonged inactivity/immobilization, depression, lactose intolerance, excess intake of alcohol/tobacco/caffeine, amenorrhea, testosterone deficiency, low BMI

treatment: exercises that optimally load the spine in neutral/ext postures (avoid flex)

primary osteoporosis

most common osteoporosis associated w/ age-related physiologic changes

secondary osteoporosis

loss of bone density due to diseases, medications, other conditions

bone strength depends on bone ___ & ___

density (how many bone cells p/mm²); quality (health of bone cells)

bone mineral density (BMD)

meshwork of Ca2+, PO4, minerals of bony tissue

peak bone mass is achieved in the ___ decade of life

3rd (if low peak, OP & fx are liekly)

disruption of osteoblastic & osteoblastic activity lead to bone ___

loss

___ stimuli may be the only stim capable of inducing modeling in mature bone

mechanical (muscle pulling on bone, activity is important)

paget disease/ostitis deformans

incr bone resorption by unrestrained osteoclasts, excessive & disorganized formation of new bone by osteoblasts → bone marrow replaced by vascular/fbrous tissue → weak, enlarged bones → deformity, fx, arthritis, pain, headache, myalgia, OA, femur pain, kyphoscoliosis, bowing, coxa varus, vertebral compression, incr CO, HF, confusion, fatigue, dizziness; 2nd most common metabolic bone disease after osteoporosis in older men

PT implications for paget disease

vague, diffuse aching pain, diffuse headaches, hearing loss/tinnitus, incontinence, diplopia, swallowing difficulties, dysarthria → comm findings to physician if undiagnosed; consider poor joint mechanics during multi-dimensional exercise (Ex-Rx: strengthing, strengthening, endurance, aerobics, balance, coordination), post-op complications (hemorrhage, infection, pathologic fx, delayed union); manage deformities via orthotics

upper GI

mouth → esophagus → stomach → duodenum; ingestion/digestion

lower GI

small intestine → large intestine; absorption of H2O & electrolytes

GI dysfunction s/s

N/V/D, anorexia, constipation, dysphagia, achalasia, heartburn, abdominal pain, GI bleeding (hematemesis, meena, hematochezia), fecal incontinence, malaise, fatigue, fever, night sweats, pallor, diaphoresis, dizziness; w/ strenuous exercise: cramps, belching, heartburn, N/V, diarrhea

age-related GI changes begin before ___ y/o

50 y/o

GI system oral changes due to aging

tooth enamel & dentin wear, tooth decay & loss, decr taste buds, decr sense of smell, depressed apetite, decr salivation

upper GI system changes due to aging

decr stomach acid → iron malabsorption, small bowel bacterial overgrowth, B12 deficiency; decr pancreatic secretions

lower GI system changes due to aging

prolonged transit time/decr neurotransmitters & receptors, constipation, less diverse microbiata, pro-inflammatory state

gastroesophageal reflux disease (GERD)

consequences from reflux of gastric contents into esophagus accompanied by failure of anatomic & physiologic mechanisms to protect the esophagus → esophagitis, strictures, barrett esophagus, gastric cancer, heartburn, belching, N/V, painful swallowing; common & chronic problem; can occur w/o visible damage to esophagus (non-erosive GERD); incr incidence w/ age, decr pressure of lower esophageal sphincter, or alteration in esophageal acid clearance

factors that incr GERD s/s

chocolate, peppermint, fatty foods, citrus, spicy foods, garlic, onions, coffee, carbonated drinks, alcohol, caffeine, obesity, smoking/nicotine, hiatal hernia, meds (morphine, diazepam, Ca2+ blockers, nitrates, aspirin, NSAIDs, dopamine, theophylline, tricyclic antidepressants, estrogen), nasogastric intubation, chronic diseases, 3rd trimester pregnancy

3 factors that keep the esophagus healthy

anatomic barriers b/n stomach & esophagus (LES impaired by low pressure or hiatal hernia), saliva & alkaline secr to clear acid, stomach acidity & acid volume

complications of GERD

esophagitis (necrosis of epithelial lining), strictures (narrow esophagus), barrett esophagus (precancerous change in cells), adenocarcinoma

GERD symptoms worsen w/ ___ ___, exercise (but still helpful)

lying down

PT implications for GERD

treatment usually includes meds & lifestyle mods; remain upright 3+ hours after meals; weight loss & elevation if obese pts; avoid meals before exercise; supine or incline positioning; prevent aspiration