Graves' Disease: Difference between revisions
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== Etiology == | == Etiology == | ||
Like all autoimmune diseases, it occurs more commonly in patients with a positive family history. It is precipitated by environmental factors eg stress, smoking, infection, iodine exposure, and postpartum, as well as after highly active antiretroviral therapy (HAART) due to immune reconstitution.<ref name=":0" /> | Like all autoimmune diseases, it occurs more commonly in patients with a positive family history. It is precipitated by environmental factors eg stress, smoking, infection, iodine exposure, and postpartum, as well as after highly active antiretroviral therapy (HAART) due to immune reconstitution.<ref name=":0" /> | ||
Having another autoimmune condition may also increase the risk of Graves’ disease. Some of these conditions include: rheumatoid arthritis; pernicious anemia; lupus; Addison’s disease; celiac disease; vitiligo; type 1 diabetes.<ref name=":1" /> | |||
== Clinical Presentation == | == Clinical Presentation == | ||
The overproduction of thyroid hormones can have a variety of effects on the body. Symptoms can include: intolerance to heat; unexplained weight loss; nervousness; sweating; hand tremors; difficulty sleeping; tiredness or weakness; irritability; frequent bowel movements or diarrhea; a goiter (an enlarged thyroid gland); an irregular or rapid heartbeat. | The overproduction of thyroid hormones can have a variety of effects on the body. Symptoms can include: intolerance to heat; unexplained weight loss; nervousness; sweating; hand tremors; difficulty sleeping; tiredness or weakness; irritability; frequent bowel movements or diarrhea; a goiter (an enlarged thyroid gland); an irregular or rapid heartbeat. | ||
In rare cases, Graves’ disease can lead to Graves’ dermopathy, which causes thick, flushed skin on the shins<ref>Medical news Today [https://www.medicalnewstoday.com/articles/170005#symptoms Graves Disease] Available:https://www.medicalnewstoday.com/articles/170005#symptoms (accessed 23.2.2022)</ref>.<ref name="Pathology" /> | In rare cases, Graves’ disease can lead to Graves’ dermopathy, which causes thick, flushed skin on the shins<ref name=":1">Medical news Today [https://www.medicalnewstoday.com/articles/170005#symptoms Graves Disease] Available:https://www.medicalnewstoday.com/articles/170005#symptoms (accessed 23.2.2022)</ref>.<ref name="Pathology" /> | ||
== | == Diagnosis == | ||
Diagnosis of Graves disease starts with a thorough history and physical examination. History should include a family history of Graves’ disease. | |||
The medical team may order: | |||
# Thyroid function tests to diagnose hyperthyroidism. The initial test is the a blood test for thyroid-stimulating hormone (TSH)<ref name=":0" />. | |||
# A radioactive iodine uptake test, which measures how much iodine the thyroid gland gathers from the bloodstream | |||
# A thyroid scan, to show how much iodine is in the thyroid gland. High levels of iodine may indicate Graves’ disease.<ref name=":1" /> | |||
== Treatment == | == Treatment == | ||
The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However | The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However: | ||
* Antithyroid drug use can cause drug-induced embryopathy in pregnancy, | |||
* Radioiodine therapy can exacerbate GO | |||
* Surgery can result in hypoparathyroidism or laryngeal nerve damage. | |||
Future studies should focus on improved drug management, and a number of important advances are on the horizon<ref>Davies TF, Andersen S, Latif R, Nagayama Y, Barbesino G, Brito M, Eckstein AK, Stagnaro-Green A, Kahaly GJ. [https://pubmed.ncbi.nlm.nih.gov/32616746/ Graves’ disease]. Nature reviews Disease primers. 2020 Jul 2;6(1):1-23.Available: https://pubmed.ncbi.nlm.nih.gov/32616746/<nowiki/>(accessed 24.2.2022)</ref>. | |||
# Antithyroid drugs: These medications work to reduce the amount of hormone that the thyroid makes. This is one of the simplest approaches hyperthyroidism<ref name=":1" />. | |||
# Radioiodine therapy: involves taking radioactive iodine orally, either in capsule or liquid form. It targets the thyroid gland and destroys the cells that produce thyroid hormone. This means that most people who have radioiodine therapy go on to develop hypothyroidism. This is much easier to manage and does not cause as many long-term health issues as hyperthyroidism.<ref name=":1" /> | |||
== Systemic Involvement == | == Systemic Involvement == | ||
[[File:Gravesdermopathy.jpg|alt=|thumb|279x279px|'''Dermopaty associated with Graves''']] | |||
Graves' Disease is a systemic autoimmune disease that effect the eyes (as seen above with Exophthalmos), skin, and thyroid gland (which regulates the body on multiple levels).<ref name="DD" /><ref name="Pathology" /><ref name="image 2">http://www.mayoclinic.com/health/medical/IM02348</ref> | |||
Central Nervous System | |||
* Tremor | * Tremor | ||
* Irritable | * Irritable | ||
| Line 76: | Line 55: | ||
* Increased motor activity | * Increased motor activity | ||
* Fatigue | * Fatigue | ||
Cardiovascular | |||
* Tachycardia | * Tachycardia | ||
* Palpitations | * Palpitations | ||
| Line 84: | Line 62: | ||
* Low blood pressure | * Low blood pressure | ||
* Heart failure | * Heart failure | ||
Integumentary | |||
* Chronic periarthritis | * Chronic periarthritis | ||
* Dilated capillaries | * Dilated capillaries | ||
| Line 92: | Line 69: | ||
* Onycholysis | * Onycholysis | ||
* Pretibial myxedema | * Pretibial myxedema | ||
Ocular | |||
* Exophthalmos | * Exophthalmos | ||
* Light sensitivity | * Light sensitivity | ||
* Vision loss | * Vision loss | ||
* Weak extraocular muscles | * Weak extraocular muscles | ||
Gastrointestinal | |||
* Increased metabolism/weight loss | * Increased metabolism/weight loss | ||
* Increased peristalsis | * Increased peristalsis | ||
* Diarrhea | * Diarrhea | ||
* Dysphagia | * Dysphagia | ||
Genitourinary | |||
* Polyuria | * Polyuria | ||
* Amenorrhea | * Amenorrhea | ||
* Female infertility | * Female infertility | ||
* Miscarriage | * Miscarriage | ||
== Physical Therapy Management == | == Physical Therapy Management == | ||
| Line 126: | Line 93: | ||
* Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. | * Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. | ||
* Impaired aerobic capacity/endurance associated with deconditioning | * Impaired aerobic capacity/endurance associated with deconditioning | ||
Hyperthyroidism has key elements that will cause a decreased tolerance to physical activity. Therapists should be sensitive to patient complaints and symptoms to note an exacerbation if the patient is already diagnosed or be able to recognize symptoms in order to refer to a physician.<ref name="DD" / | Hyperthyroidism has key elements that will cause a decreased tolerance to physical activity. Therapists should be sensitive to patient complaints and symptoms to note an exacerbation if the patient is already diagnosed or be able to recognize symptoms in order to refer to a physician.<ref name="DD" /> | ||
=== Precautions for Graves Related Hyperthyroidism === | === Precautions for Graves Related Hyperthyroidism === | ||
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#Medications can fluctuate the thyroid hormones to either send the patient into Hypothyroidism or Hyperthyroidism. It is imperative to watch for symptoms or patient complaints that may indicate a fluctuation and refer the patient back to their endocrinologist since these two extremes will vary tolerance for physical activity.<ref name="DD" /><ref name="Pathology" /> | #Medications can fluctuate the thyroid hormones to either send the patient into Hypothyroidism or Hyperthyroidism. It is imperative to watch for symptoms or patient complaints that may indicate a fluctuation and refer the patient back to their endocrinologist since these two extremes will vary tolerance for physical activity.<ref name="DD" /><ref name="Pathology" /> | ||
# If a patient has recently had surgery or radioiodine treatment it is possible that you will see hypothyroidism.<ref name="Franklyn" /> | # If a patient has recently had surgery or radioiodine treatment it is possible that you will see hypothyroidism.<ref name="Franklyn">Franklyn J. The management of Hyperthyroidism. New England Journal of Medicine. 1994; 331(8):559.</ref> | ||
#If a patient is on Beta-blockers for management tremors, anxiety, and palpitations during the exacerbation period, the therapist must be aware fo the physiological effects this can have on a patient during physical therapy.<ref name="Franklyn" />Therefore, a better measurement of vitals is the rate of perceived exertion.<ref name="Pathology" / | #If a patient is on Beta-blockers for management tremors, anxiety, and palpitations during the exacerbation period, the therapist must be aware fo the physiological effects this can have on a patient during physical therapy.<ref name="Franklyn" />Therefore, a better measurement of vitals is the rate of perceived exertion.<ref name="Pathology" /> | ||
=== Precautions/Symptoms Related to Hypothyroidism === | === Precautions/Symptoms Related to Hypothyroidism === | ||
| Line 162: | Line 129: | ||
*Congestive Heart Failure | *Congestive Heart Failure | ||
<ref name="DD" /><ref name="Pathology" /><ref name="Fukushima" /> | <ref name="DD" /><ref name="Pathology" /><ref name="Fukushima">Fukushima H, Matsuo H, Imamura K, et al. Diagnosis and discrimination of autoimmune graves’ diseas nad Hashimoto’s disease using thyroid stimulation hormone receptor-containing recombinant proteoliposomes. Journal of Bioscience and Bioengineering. 2009. 108(6):551-56.</ref> | ||
== Resources == | == Resources == | ||
* [http://www.ngdf.org/ National Graves' Disease Foundation] | * [http://www.ngdf.org/ National Graves' Disease Foundation] | ||
Revision as of 02:03, 24 February 2022
Original Editors - Erin Shinkle from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Erin Shinkle, Elaine Lonnemann, Lucinda hampton, Admin, Kim Jackson, WikiSysop, Wendy Walker and Andeela Hafeez
Introduction[edit | edit source]
Graves’ disease (GD), the most common cause of hyperthyroidism, is an autoimmune condition that affects the thyroid gland, causing an overproduction of thyroid hormones. The treatment is relatively simple, but without it, the disease can have serious effects. Failure to diagnose Graves' disease can predispose thyroid storm which carries high morbidity and mortality[1].
Graves' disease primarily affects the thyroid gland but may also affect multiple other organs including eyes and skin.[1].
Epidemiology[edit | edit source]
Graves’ disease is more prevalent in the Caucasian race affecting more women than men, between the ages of 30 and 60.[2][3] Graves’ disease accounts for 85% of all cases of hyperthyroidism. [4]
Etiology[edit | edit source]
Like all autoimmune diseases, it occurs more commonly in patients with a positive family history. It is precipitated by environmental factors eg stress, smoking, infection, iodine exposure, and postpartum, as well as after highly active antiretroviral therapy (HAART) due to immune reconstitution.[1]
Having another autoimmune condition may also increase the risk of Graves’ disease. Some of these conditions include: rheumatoid arthritis; pernicious anemia; lupus; Addison’s disease; celiac disease; vitiligo; type 1 diabetes.[5]
Clinical Presentation[edit | edit source]
The overproduction of thyroid hormones can have a variety of effects on the body. Symptoms can include: intolerance to heat; unexplained weight loss; nervousness; sweating; hand tremors; difficulty sleeping; tiredness or weakness; irritability; frequent bowel movements or diarrhea; a goiter (an enlarged thyroid gland); an irregular or rapid heartbeat.
In rare cases, Graves’ disease can lead to Graves’ dermopathy, which causes thick, flushed skin on the shins[5].[4]
Diagnosis[edit | edit source]
Diagnosis of Graves disease starts with a thorough history and physical examination. History should include a family history of Graves’ disease.
The medical team may order:
- Thyroid function tests to diagnose hyperthyroidism. The initial test is the a blood test for thyroid-stimulating hormone (TSH)[1].
- A radioactive iodine uptake test, which measures how much iodine the thyroid gland gathers from the bloodstream
- A thyroid scan, to show how much iodine is in the thyroid gland. High levels of iodine may indicate Graves’ disease.[5]
Treatment[edit | edit source]
The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However:
- Antithyroid drug use can cause drug-induced embryopathy in pregnancy,
- Radioiodine therapy can exacerbate GO
- Surgery can result in hypoparathyroidism or laryngeal nerve damage.
Future studies should focus on improved drug management, and a number of important advances are on the horizon[6].
- Antithyroid drugs: These medications work to reduce the amount of hormone that the thyroid makes. This is one of the simplest approaches hyperthyroidism[5].
- Radioiodine therapy: involves taking radioactive iodine orally, either in capsule or liquid form. It targets the thyroid gland and destroys the cells that produce thyroid hormone. This means that most people who have radioiodine therapy go on to develop hypothyroidism. This is much easier to manage and does not cause as many long-term health issues as hyperthyroidism.[5]
Systemic Involvement[edit | edit source]
File:Gravesdermopathy.jpg
Dermopaty associated with Graves
Graves' Disease is a systemic autoimmune disease that effect the eyes (as seen above with Exophthalmos), skin, and thyroid gland (which regulates the body on multiple levels).[2][4][7]
Central Nervous System
- Tremor
- Irritable
- Labile emotions
- Muscle weakness and myopathy
- Increased DTR
- Increased motor activity
- Fatigue
Cardiovascular
- Tachycardia
- Palpitations
- Repiratory muscle weakness
- Increased RR and HR
- Low blood pressure
- Heart failure
Integumentary
- Chronic periarthritis
- Dilated capillaries
- Heat intolerance
- Brittle hair
- Onycholysis
- Pretibial myxedema
Ocular
- Exophthalmos
- Light sensitivity
- Vision loss
- Weak extraocular muscles
Gastrointestinal
- Increased metabolism/weight loss
- Increased peristalsis
- Diarrhea
- Dysphagia
Genitourinary
- Polyuria
- Amenorrhea
- Female infertility
- Miscarriage
Physical Therapy Management [edit | edit source]
Graves' disease is not directly managed by physical therapy but precautions and understanding of the disease are necessary when working with these patients. Deconditioning and muscle weakness are secondary ailments that is seen in this population and can be managed by a physical therapist.[4]
Perferred Practice Patterns[4][edit | edit source]
- Impaired Muscle performance
- Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction.
- Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation.
- Impaired aerobic capacity/endurance associated with deconditioning
Hyperthyroidism has key elements that will cause a decreased tolerance to physical activity. Therapists should be sensitive to patient complaints and symptoms to note an exacerbation if the patient is already diagnosed or be able to recognize symptoms in order to refer to a physician.[2]
Precautions for Graves Related Hyperthyroidism[edit | edit source]
- Decreased Cardiorespiratory function causing dyspnea on exertion and tachycardia
- Palpitations/Atrial Fibrillation (therefore therapist should be monitoring vital signs and symptoms)
- Decreased efficiency of oxygen uptake in peripheral musculature
- Heat intolerance is seen in Grave's disease
- Myopathies and proximal muscle weakness
All of these are reversible with the management of thyroid hormones and acheivement of Euthyroid. [2][8]
The therapist should have a base knowledge and understanding of the medication and or surgeries that these patients have undergone. The reasons are as follows:
- Medications can fluctuate the thyroid hormones to either send the patient into Hypothyroidism or Hyperthyroidism. It is imperative to watch for symptoms or patient complaints that may indicate a fluctuation and refer the patient back to their endocrinologist since these two extremes will vary tolerance for physical activity.[2][4]
- If a patient has recently had surgery or radioiodine treatment it is possible that you will see hypothyroidism.[9]
- If a patient is on Beta-blockers for management tremors, anxiety, and palpitations during the exacerbation period, the therapist must be aware fo the physiological effects this can have on a patient during physical therapy.[9]Therefore, a better measurement of vitals is the rate of perceived exertion.[4]
Precautions/Symptoms Related to Hypothyroidism[edit | edit source]
If the patient is on medication or is post-surgical there are certain things that need to be taken into consideration: [4]
- Excessive fatigue and apathy
- Sensitivity to cold
- Weight gain/ dry brittle hair/ and other
- Decreased cardiac output, low pulse and poor circulation
- Ataxia, intention tremor, and nystagmus
Differential Diagnosis[edit | edit source]
- Hyperthyroidism
- Thyroid Storm
- Hyperparathyroidism
- Thyroid cancer
- Myasthenia gravis
- Psychological disorders (anxiety, panic attacks, or mood disorders)
- Atrial Fibrillation
- Congestive Heart Failure
Resources[edit | edit source]
- National Graves' Disease Foundation
- American Thyroid Association (ATA)
- American Association of Clinical Endocrinologists (AACE)
- The Endocrine Society
- The Hormone Foundation
- American Autoimmune Related Diseases Associations (AARDA)
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 Pokhrel B, Bhusal K. Graves disease. StatPearls [Internet]. 2021 Jul 21.Available: https://www.ncbi.nlm.nih.gov/books/NBK448195/(accessed 23.2.2022)
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier, 2007.
- ↑ Hemminki K, Li X, Sundquist J, Sundquist K. The epidemiology of Graves’ disease: Evidence of a genetic and an environmental contribution. Journal of Autoimmunity 2010; 34:307-13.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.
- ↑ 5.0 5.1 5.2 5.3 5.4 Medical news Today Graves Disease Available:https://www.medicalnewstoday.com/articles/170005#symptoms (accessed 23.2.2022)
- ↑ Davies TF, Andersen S, Latif R, Nagayama Y, Barbesino G, Brito M, Eckstein AK, Stagnaro-Green A, Kahaly GJ. Graves’ disease. Nature reviews Disease primers. 2020 Jul 2;6(1):1-23.Available: https://pubmed.ncbi.nlm.nih.gov/32616746/(accessed 24.2.2022)
- ↑ http://www.mayoclinic.com/health/medical/IM02348
- ↑ Mercuro G, Panzuto MG, Bina A, et al. Cardiac function, physical exercise Capacity, and quality of Life during long term thyrotropin-suppressive therapy with Levothyroxine: Effect of individual Dose Tailoring. J of Clinical endocrinology and metabolism. 2000 85: 159-164.
- ↑ 9.0 9.1 Franklyn J. The management of Hyperthyroidism. New England Journal of Medicine. 1994; 331(8):559.
- ↑ Fukushima H, Matsuo H, Imamura K, et al. Diagnosis and discrimination of autoimmune graves’ diseas nad Hashimoto’s disease using thyroid stimulation hormone receptor-containing recombinant proteoliposomes. Journal of Bioscience and Bioengineering. 2009. 108(6):551-56.
