Graves' Disease: Difference between revisions

No edit summary
m (Lucinda hampton moved page Grave's Disease to Graves' Disease: corrected spelling)
 
(32 intermediate revisions by 7 users not shown)
Line 1: Line 1:
   
   
<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
<div class="editorbox">
'''Original Editors '''- Erin Shinkle [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- Erin Shinkle [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp;  
</div>  
</div>  
== Definition/Description ==
== Introduction ==
[[File:Proptosis and lid retraction from Graves' Disease.jpeg|thumb|Classic finding: Graves' Disease-proptosis and lid retraction.|alt=]]Graves’ disease (GD), the most common cause of [[hyperthyroidism]], is an [[Autoimmune Disorders|autoimmune disorder]] that affects the [[Thyroid Gland|thyroid gland]]. Graves’ disease causes the immune system to attack the thyroid, leading to excess thyroid hormone production. The treatment is relatively simple, but without it, the disease can have serious effects. Failure to diagnose Graves' disease can predispose [[Thyroid Storm (Thyroid Crisis)|thyroid storm]] which carries high morbidity and mortality<ref name=":0">Pokhrel B, Bhusal K. [https://www.ncbi.nlm.nih.gov/books/NBK448195/ Graves disease]. StatPearls [Internet]. 2021 Jul 21.Available: https://www.ncbi.nlm.nih.gov/books/NBK448195/<nowiki/>(accessed 23.2.2022)</ref>.


Graves’ is classified as an autoimmune disease that affects the thyroid gland. It causes goiters, hyperthyroidism, ophthalmopathy, and occasionally dermopathy. <ref name="Ginsberg">Ginsberg J. Diagnosis and Management of Graves’ Disease. Canadian Medical Associates Journal. 2003; 168(5):575-85.</ref> Graves'&nbsp; disease is known for increasing the thyroid stimulating hormone which either raises the thyroxine (T4) levels which leads to [[Hyperthyroidism|hyperthyroidism]] symptoms or in approximately 10% of&nbsp; graves' disease cases there is a raise triiodothyronine (T3) levels with both TSH and T4 levels normal which is a possible precurser to graves disease.<ref name="Ginsberg" /> <ref name="DD">Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier, 2007.</ref><br>
Graves' disease primarily affects the thyroid gland but may also affect multiple other organs including eyes and skin.<ref name=":0" />.


<br>  
== Etiology ==
[[File:Thyroid and release.jpeg|thumb|Thyroid function]]
Like all autoimmune diseases, it occurs more commonly in patients with a positive family history. It is precipitated by environmental factors eg [[Stress and Health|stress]], [[Smoking Cessation and Brief Intervention|smoking]], [[Infectious Disease|infection]], iodine exposure, and postpartum, as well as after highly active [[Antiviral Drugs|antiretroviral therapy]] (HAART) due to immune reconstitution.<ref name=":0" />


''Manifestation of the Autoimmune Graves Disease ''(ginsberg)<br>  
Having another autoimmune condition may also increase the risk of Graves’ disease. Some of these conditions include: [[Rheumatoid Arthritis|rheumatoid arthritis]]; pernicious [[anemia]]; [[Systemic Lupus Erythematosus|lupus]]; [[Addison's Disease|Addison’s disease]]; [[Celiac Disease (Coeliac Disease)|celiac]] disease; [[Diabetes Mellitus Type 1|type 1 diabetes]].<ref name=":1" />


[[Image:22ff1.gif|674x575px]]
== Clinical Presentation ==
The overproduction of thyroid [[Hormones|hormone]]<nowiki/>s 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.


== Prevalence  ==
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">Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.</ref>
== Diagnosis ==
[[File:Thyroid Gland- location.png|thumb]]
Diagnosis of Graves disease starts with a thorough history and physical examination. History should include a family history of Graves’ disease.


Graves’ disease is more prevalent in the Caucasian race affecting more women than men at a ratio of 4:1 and ages range from 30-60years.<ref name="DD" /><ref name="Heemminki">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.</ref> Graves’ disease accounts for 85% of all cases of hyperthyroidism.&nbsp;<ref name="Pathology">Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.</ref>
The medical team may order:


<br>
# Thyroid function tests to diagnose hyperthyroidism. The initial test is the a [[Blood Tests|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 [[Blood Physiology|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" />


== Characteristics/Clinical Presentation  ==
== Treatment ==
The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However:


Goiter, Exophthalmos, tremors, dermopaty, tachycardia with palpitations, heat intolerances, weight loss, increased deep tendon reflexes, weakness and muscle atrophy, increased cardiac output, myasthenia gravis, thin hair, warm moist skin, sensitivity to light, dysphasia, diarrhea, amenorrhea, polyuria, and many other presentations, some of which may not be as common and more subtle.<ref name="Pathology" /><br>
* Antithyroid drug use can cause drug-induced embryopathy in pregnancy,  
* Radioiodine therapy can exacerbate graves' orbitopathy
* Surgery can result in hypoparathyroidism or laryngeal nerve damage.  


<br>
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>.
 
'''Most common diagnostic symptom<ref name="image 1">http://www.nlm.nih.gov/medlineplus/ency/imagepages/17067.htm</ref>'''
 
[[Image:Wiki image 1.jpg|Image:Wiki_image_1.jpg]]<br>
 
== Associated Co-morbidities  ==
 
Rhuematoid arthritis is one of the major associated autoimmune diseases along with Systematic lupus. There is an overall raise in incidence for a co-morbidity of any autoimmune diseases.<ref name="Boelaert">Boelaert K, Newby PR, Simmonds MJ, Holder RL, et al.Prevalence and relative risk of other autommune diseases in subjects with autoimmune thyroid disorders.  American Journal of Medicine. 2010 Feb;123(2):183.</ref> Recommendation for futher autoimmune disease screening may be warrented with the diagnosis of Graves' disease.&nbsp;
 
<br>
 
There is also an increased risk of cancer in the thyroid nodules associated with Graves' disease and further ultrasonography imaging and/or biopsy may be needed for further testing if suspected malignancy.<ref name="Ginsberg" /><ref name="Pathology" /><br>
 
<br>
 
Thyroid Storm: Caused from uncontrolled hyperthyroidis or other factors like traumatic injury or infection. Therapist should be aware of this complications signs and symptoms which are as follows:
 
*Severe tachycardia with heart failure
*Hyperurthemia (up to 105 degrees)
*Reselessness and agitation
*Abdominal pain, nausea, and vomiting
*Possible coma
 
Immediate referral is necessary.<ref name="DD" />
 
== Medications  ==
 
'''Antithyroid drugs''' have the main effect of inhibition of thyroid hormones as well as a secondary purpose of reduction of thyrotropin-receptor antibodies and increasing supressor T-cells. These drugs are used mainly for controlling the thyroid in hopes to create a stable thyroid and have a remission period rom Graves' Disease.<ref name="Franklyn">Franklyn J. The management of Hyperthyroidism. New England Journal of Medicine. 1994; 331(8):559.</ref> The three main medications are Methimazole, Carbimazole, and Propylthiouracil. The most perferred medication is methimazole, however, there are no significant differences among the antithyroid drugs in their success rates.<ref name="Cooper">Cooper D. Antithyroid drugs in the management of patients with Graves’ disease: An evidence based approach to therapeutic controversies. Journal of Clinical Endocrine and Metabolism.  2003; 88:3474-81.</ref><br>
 
<br>
 
'''Beta Adrenergic- Antagonist Drugs '''is used for treatment of symptoms such as tremors, anxiety, and palpitations. This medication is used as an adjunct therapy to other means of management for Graves disease.<ref name="Cooper" />
 
<br>
 
'''Inorganic Iodide '''is used only for short term reduction of thyroid hormones lasting effects from days to a few weeks.<ref name="Cooper" /><br>
 
<br>
 
'''Radioiodine Therapy '''is becoming a more popular means of treatment which is used to destroy thyroid tissue with the ultimate goal of balanced thyroid hormones or [[Hypothyroidism|hypothyriodism]].<ref name="Cooper" />
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
Thyroid blood serum testsare taken A positive test results include a decreased or normal TSH levels, elevated free thyroxine t4 diagnosis of hyperthyriodism. To specify graves disease Radioiodine uptake test is used.<ref name="Ginsberg" />
 
Thyroid stimulating Hormone Antibodies (TRAb) and thyroid peroxidase autoantibodies (TPOAb) may be found in most patients, but is not needed for specific diagnosis since most patients are diagnosed with blood serum tests and symptomology.<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>
 
== Etiology/Causes  ==
 
Has both genetic causes, lack of suppressor t-cells causing increase in TSH receptor antibodies, and environmental causes which includes, but not limited to the following: stress, smoking, post pardum, and infections.<ref name="Ginsberg" /><ref name="Heemminki" /><br><br>
 
== Systemic Involvement  ==
 
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" /><br>
 
'''Dermopaty associated with Graves'<ref name="image 2">http://www.mayoclinic.com/health/medical/IM02348</ref>'''
 
[[Image:Gravesdermopathy.jpg|248x279px]]<br>
 
<br> '''Systemic involvement of hyperthyroid symptoms in Graves' Disease.&nbsp;<ref name="Pathology" />'''
 
<u>'''Central Nervous System'''</u>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>
 
• Tremor<br>• Irritable<br>• Labile emotions<br>• Muscle weakness and myopathy<br>• Increased DTR<br>• Increased motor activity<br>• Fatigue
 
<u>'''Cardiovascular'''</u>
 
• Tachycardia<br>• Palpitations<br>• Repiratory muscle weakness<br>• Increased RR and HR<br>• Low blood pressure<br>• Heart failure
 
<u>'''Integumentary'''</u><br>
 
• Chronic periarthritis<br>• Dilated capillaries<br>• Heat intolerance<br>• Brittle hair<br>• Onycholysis<br>•Pretibial myxedema<br>
 
<u>'''Ocular'''</u>
 
• Exophthalmos<br>• light sensitivity<br>• vision loss<br>• weak extraocular muscles<br>
 
'''<u>Gastrointestinal</u>'''
 
• Increased metabolism/weight loss<br>• Increased peristalsis<br>• Diarrhea<br>• Dysphagia<br>
 
<u>'''Genitourinary'''</u>
 
• Polyuria<br>• Amenorrhea<br>• Female infertility<br>• Miscarriage
 
== Medical Management (current best evidence)<br>  ==
 
The current best management of Graves' disease varies upon several factors of the individual recieving it. The options include partial and full removal of thyroid gland, antithyroid drug therapy, and radioiodine therapy.<ref name="Franklyn" /><ref name="Koyuncu">Koyuncu A, AYdin C, Topcu O, et Al. Could thyroidectomy become the stansard treatment for Graves’ Disease? Surgery Today. 2010. 40:22-25.</ref>&nbsp; There are adjunct treatments for symptom management until euthyroid is acheived through medical management. <br>
 
<br>
 
Current clinical practice suggests that radioiodine therapy is the primary choice of treatment for Graves' disease, then either antithyriod drugs or surgery depending on the contraindications for one or the other.<ref name="Panareo">Panareo S, Rossi R, Fabbri S, et al. A practical method for the estimation of therapeutic activity in the treatment of Graves’ Disease hyperthyroidism. J of Nucl Med Mol Imaging. 2010. 54:1-9.</ref>
 
<br>


# 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" />
== Physical Therapy Management&nbsp;  ==
== Physical Therapy Management&nbsp;  ==


Graves' disease is not directly managed by physical therapy but percautions and understanding of the disease is 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.<ref name="Pathology" />
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.<ref name="Pathology" />
 
'''Perferred Practice Patterns<ref name="Pathology" />'''
 
4C: Impaired Muscle performance<br>
 
4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction.
 
4E: impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation.
 
6B: Impaired aerobic coapcity/endurance associated with deconditioning
 
<br>
 
<br>  


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 patient is already diagnosed or be able to recognize symptoms in order to refer to physician.<ref name="DD" /><br>  
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">Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier, 2007.</ref>


<br>
=== Precautions for Graves Related Hyperthyroidism ===
 
*Decreased Cardiorespiratory function causing dyspnea on exertion and tachycardia  
'''<u>Percautions for Graves Related Hyperthyroidism</u>'''<br>
 
*Decreased Cardiorespiratory function causing dypsnea on exertion and tachycardia<br>
*Palpitations/Atrial Fibrillation (therefore therapist should be monitoring vital signs and symptoms)  
*Palpitations/Atrial Fibrillation (therefore therapist should be monitoring vital signs and symptoms)  
*Decreased efficiency of oxygen uptake in peripheral musculature  
*Decreased efficiency of oxygen uptake in peripheral musculature  
Line 153: Line 56:
All of these are reversible with the management of thyroid hormones and acheivement of Euthyroid.&nbsp;<ref name="DD" /><ref name="Mercuro">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.</ref>  
All of these are reversible with the management of thyroid hormones and acheivement of Euthyroid.&nbsp;<ref name="DD" /><ref name="Mercuro">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.</ref>  


<br>
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:  
 
<br>
 
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 fluxuate the thyroid hormones to either send patient into Hypothyroidism or Hyperthyroidism. It is imparative to watch for symptoms or patient complaints that may indicate a fluxuation and refer patient back to their endocrinologist since these two extremes will vary tolerance for physical activity.<ref name="DD" /><ref name="Pathology" />
#&nbsp;If patient has recently had surgery or radioiodine treatment it is possible that you will see hypothyroidism.<ref name="Franklyn" />
#If patient is on Beta blockers for management tremors, anxiety, and palpitations during 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 rate of percieved exertion.<ref name="Pathology" />


<br>  
#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" />
#&nbsp;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" />


<u>'''Percautions/Symptoms related to hypothyroidism (if patient on medication or post surgical)&nbsp;<ref name="Pathology" />'''</u>
=== Precautions/Symptoms Related to Hypothyroidism ===
 
If the patient is on medication or is post-surgical there are certain things that need to be taken into consideration:&nbsp;<ref name="Pathology" />
*Excessive fatigue and apathy<br>
*Excessive fatigue and apathy  
*Sensitivity to cold  
*Sensitivity to cold  
*Weight gain/ dry brittle hair/ and other  
*Weight gain/ dry brittle hair/ and other  
*Decreased cardiac output, low pulse and poor circulation  
*Decreased cardiac output, low pulse and poor circulation  
*Ataxia, intention tremor, and nystagmus <br>
*Ataxia, intention tremor, and nystagmus  
 
== Alternative/Holistic Management (current best evidence)  ==
 
''"'''Ahnjeonbaekho-tang (AJBHT)''', an herbal remedy for Graves’ disease, consists of eight medicinal herbs, including Pueraria thunbergiana and Scutellaria baicalensis, which are the main herbs regulating thyroid hormone.&nbsp; Puerariathunbergiana contains isoflavones, such as daidzein,daidzein, puerarin, and puerarin xyloside. The main componentsof Scutellaria baicalensis are baicalein, baicalin,chrysin, oroxylin, wogonin, and wogonoside.&nbsp; Among these components, daidzein and baicalein are known to have antithyroid effects. Recently, we reported that AJBHT treatment can improve clinical symptoms and decrease levelsof thyroid hormone in Graves’ disease patients who have sideeffects from antithyroid drugs..."'' - '''This holistic approach was done in a clinical trial for treatment of Graves' disease. Although the trial revealed a decrease in both T3 and T4 thyroid hormones and an increase in Thyroid stimulating hormone, this is only one clinical trail and is not suffiecient evidence to support the use of AJBHT.''' <ref name="Lee">Lee BC, Kang SI, Ahn YM, et al. An alternative therapy for Graves’ disease: Clinical Effects and Mechanisms of an Herbal Remedy. Biol. Pharm. Bull. 2008. 31(4) 583—587.</ref><br>
 
<br>
 
'''Bugleweed and Lemonbalm''': In combination with lemonbalm this plant is said to decrease thyroidd stimulating hormones and T4 levels. Bungleweed, along with lemonbalm help block the graves disease causing antibodies from binding to the thyroid gland.<ref>UofMhealth. Bugleweed. http://www.uofmhealth.org/health-library/hn-2055003#hn-2055003-uses.  (accessed 29 Mar 2011).</ref><ref>UofMhealth. Lemon balm. http://www.uofmhealth.org/health-library/hn-2121004#hn-2121004-uses. (accessed 29 Mar 2011).</ref>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 
Bugleweed Picture<ref>http://home.howstuffworks.com/bugleweed.htm</ref> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; Lemonbalm Picture<ref>http://destinyhealth4u4evercatherineshanahan.blogspot.com/2010/06/my-5-top-mood-boosters.html</ref>&nbsp; <br>
 
[[Image:Bugleweed-1.jpg|278x180px]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Lemon-Balm-2z.jpg|291x242px]]&nbsp;
 
<br>
 
As with many other alternative therapies, these methods have limited clinical evidence to support the use of these herbs for Graves' Disease.<br>


== Differential Diagnosis  ==
== Differential Diagnosis  ==


*Hyperthyroidism  
*[[Hyperthyroidism]]
*Thyroid Storm  
*[[Thyroid Storm (Thyroid Crisis)|Thyroid Storm]]
*Hyperparathyroidism  
*[[Hyperparathyroidism]]
*Tyroid cancer  
*[[Thyroid Cancer|Thyroid cancer]]
*Myasthenia gravis  
*[[Myasthenia Gravis|Myasthenia gravis]]
*Psychological disorders (anxiety, panic attacks, or mood disorders)<br>
*Psychological disorders (anxiety, panic attacks, or mood disorders)  
*Atrial Fibrilation
*[[Atrial Fibrillation]]
*Congestive Heart Failure<br>
*Congestive Heart Failure
 
<ref name="DD" /><ref name="Pathology" /><ref name="Fukushima" />
 
== Case Reports/ Case Studies  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])
 
== Related Articles (from Pubmed)  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=129mA77YOoVgFoCXx_rkYBbrw3zdVAHK4wr_5RPyB-clEKnMnJ|charset=UTF-8|short|max=10</rss></div>
== Resources <br>  ==
 
National Graves' Disease Foundation<br>
 
&nbsp; &nbsp;&nbsp;&nbsp; http://www.ngdf.org/<br>
 
<br>American Thyroid Association (ATA) <br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; http://thyroid.org/<br> <br>American Association of Clinical Endocrinologists (AACE)<br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; http://www.aace.com/<br> <br>The Endocrine Society<br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; http://www.endo-society.org/<br><br>The Hormone Foundation<br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; http://www.hormone.org/<br> <br>American Autoimmune Related Diseases Associations (AARDA)<br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; http://www.aarda.org/
 
<br>
 
<br>


<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>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Bellarmine_Student_Project]]
[[Category:Bellarmine_Student_Project]]
[[Category:Autoimmune Disorders]]

Latest revision as of 01:36, 26 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]

Classic finding: Graves' Disease-proptosis and lid retraction.

Graves’ disease (GD), the most common cause of hyperthyroidism, is an autoimmune disorder that affects the thyroid gland. Graves’ disease causes the immune system to attack the thyroid, leading to excess thyroid hormone production. 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].

Etiology[edit | edit source]

Thyroid function

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; type 1 diabetes.[2]

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[2].[3]

Diagnosis[edit | edit source]

Thyroid Gland- location.png

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:

  1. Thyroid function tests to diagnose hyperthyroidism. The initial test is the a blood test for thyroid-stimulating hormone (TSH)[1].
  2. A radioactive iodine uptake test, which measures how much iodine the thyroid gland gathers from the bloodstream
  3. A thyroid scan, to show how much iodine is in the thyroid gland. High levels of iodine may indicate Graves’ disease.[2]

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 graves' orbitopathy
  • 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[4].

  1. Antithyroid drugs: These medications work to reduce the amount of hormone that the thyroid makes. This is one of the simplest approaches hyperthyroidism[2].
  2. 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.[2]

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.[3]

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.[5]

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. [5][6]

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:

  1. 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.[5][3]
  2.  If a patient has recently had surgery or radioiodine treatment it is possible that you will see hypothyroidism.[7]
  3. 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.[7]Therefore, a better measurement of vitals is the rate of perceived exertion.[3]

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: [3]

  • 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]

[5][3][8]

References[edit | edit source]

  1. ↑ 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. ↑ 2.0 2.1 2.2 2.3 2.4 Medical news Today Graves Disease Available:https://www.medicalnewstoday.com/articles/170005#symptoms (accessed 23.2.2022)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.
  4. ↑ 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)
  5. ↑ 5.0 5.1 5.2 5.3 Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier, 2007.
  6. ↑ 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.
  7. ↑ 7.0 7.1 Franklyn J. The management of Hyperthyroidism. New England Journal of Medicine. 1994; 331(8):559.
  8. ↑ 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.
Retrieved from "https://www.physio-pedia.com/index.php?title=Graves%27_Disease&oldid=295232"