HYPERTHYROIDISM

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hyperthyroidism is a condition of the thyroid. The thyroid is a small, butterfly-shaped gland located at the front of your neck. It produces tetraiodothyronine (T4) and triiodothyronine (T3), which are two primary hormones that control how your cells use energy. Your thyroid gland regulates your metabolism through the release of these hormones.

Hyperthyroidism occurs when the thyroid makes too much T4, T3, or both. Diagnosis of overactive thyroid and treatment of the underlying cause can relieve symptoms and prevent complications.

causes-

A variety of conditions can cause hyperthyroidism. Graves’ disease, an autoimmune disorder, is the most common cause of hyperthyroidism. It causes antibodies to stimulate the thyroid to secrete too much hormone. Graves’ disease occurs more often in women than in men. It tends to run in families, which suggests a genetic link. You should tell your doctor if your relatives have had the condition.

Other causes of hyperthyroidism include:

• excess iodine, a key ingredient in T4 and T3
• thyroiditis, or inflammation of the thyroid, which causes T4 and T3 to leak out of the gland
• tumors of the ovaries or testes
• benign tumors of the thyroid or pituitary gland
• large amounts of tetraiodothyronine taken through dietary supplements or medication

symptoms-

High amounts of T4, T3, or both can cause an excessively high metabolic rate. This is called a hypermetabolic state. When in a hypermetabolic state, you may experience a rapid heart rate, elevated blood pressure, and hand tremors. You may also sweat a lot and develop a low tolerance for heat. Hyperthyroidism can cause more frequent bowel movements, weight loss, and, in women, irregular menstrual cycles.

Visibly, the thyroid gland itself can swell into a goiter, which can be either symmetrical or one-sided. Your eyes may also appear quite prominent, which is a sign of exophthalmos, a condition that’s related to Graves’ disease.

Other symptoms of hyperthyroidism include:

• increased appetite
• nervousness
• restlessness
• inability to concentrate
• weakness
• irregular heartbeat
• difficulty sleeping
• fine, brittle hair
• itching
• hair loss
• nausea and vomiting
• breast development in men

The following symptoms require immediate medical attention:

• dizziness
• shortness of breath
• loss of consciousness
• fast, irregular heart rate

Hyperthyroidism can also cause atrial fibrillation, a dangerous arrhythmia that can lead to strokes, as well as congestive heart failure.

How do doctors diagnose hyperthyroidism?

Your doctor will take a medical history and do a physical exam, but also will need to do some tests to confirm a diagnosis of hyperthyroidism. Many symptoms of hyperthyroidism are the same as those of other diseases, so doctors usually can’t diagnose hyperthyroidism based on symptoms alone.

Because hypothyroidism can cause fertility problems, women who have trouble getting pregnant often get tested for thyroid problems.

Your doctor may use several blood tests to confirm a diagnosis of hyperthyroidism and find its cause. Imaging tests, such as a thyroid scan, can also help diagnose and find the cause of hyperthyroidism.

Your first step in diagnosis is to get a complete medical history and physical exam. This can reveal these common signs of hyperthyroidism:

• weight loss
• rapid pulse
• elevated blood pressure
• protruding eyes
• enlarged thyroid gland

Other tests may be performed to further evaluate your diagnosis. These include:

Cholesterol test

Your doctor may need to check your cholesterol levels. Low cholesterol can be a sign of an elevated metabolic rate, in which your body is burning through cholesterol quickly.

T4, free T4, T3

These tests measure how much thyroid hormone (T4 and T3) is in your blood.

Thyroid stimulating hormone level test

Thyroid stimulating hormone (TSH) is a pituitary gland hormone that stimulates the thyroid gland to produce hormones. When thyroid hormone levels are normal or high, your TSH should be lower. An abnormally low TSH can be the first sign of hyperthyroidism.

Triglyceride test

Your triglyceride level may also be tested. Similar to low cholesterol, low triglycerides can be a sign of an elevated metabolic rate.

Thyroid scan and uptake

This allows your doctor to see if your thyroid is overactive. In particular, it can reveal whether the entire thyroid or just a single area of the gland is causing the overactivity.

Ultrasound

Ultrasounds can measure the size of the entire thyroid gland, as well as any masses within it. Doctors can also use ultrasounds to determine if a mass is solid or cystic.

CT or MRI scans

A CT or MRI can show if a pituitary tumor is present that’s causing the condition.

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What are my hyperthyroidism treatment options?

You may receive medicines, radioiodine therapy, or thyroid surgery to treat your hyperthyroidism. The aim of treatment is to bring thyroid hormone levels back to normal to prevent long-term health problems and to relieve uncomfortable symptoms. No single treatment works for everyone.

Treatment depends on the cause of your hyperthyroidism and how severe it is. When recommending a treatment, your doctor will consider your age, possible allergies to or side effects of the medicines, other conditions such as pregnancy or heart disease, and whether you have access to an experienced thyroid surgeon.

Medicines

Beta blockers. Beta blockers do not stop thyroid hormone production, but can reduce symptoms until other treatments take effect. Beta blockers act quickly to relieve many of the symptoms of hyperthyroidism, such as tremors, rapid heartbeat, and nervousness. Most people feel better within hours of taking beta blockers.

Antithyroid medicines. Antithyroid therapy is the simplest way to treat hyperthyroidism. Antithyroid medicines cause the thyroid to make less thyroid hormone. These medicines usually don’t provide a permanent cure. Health care providers most often use the antithyroid medicine methimazole. Health care providers more often treat pregnant women with propylthiouracil during the first 3 months of pregnancy, however, because methimazole can harm the fetus, although this happens rarely.

Once treatment with antithyroid medicine begins, your thyroid hormone levels may not move into the normal range for several weeks or months. The total average treatment time is about 1 to 2 years, but treatment can continue for many years. Antithyroid medicines are not used to treat hyperthyroidism caused by thyroiditis.

Antithyroid medicines can cause side effects in some people, including

• allergic reactions such as rashes and itching
• a decrease in the number of white blood cells in your body, which can lower resistance to infection
• liver failure, in rare cases

Call your doctor right away if you have any of the following symptoms:

• fatigue
• weakness
• dull pain in your abdomen
• loss of appetite
• skin rash or itching
• easy bruising
• yellowing of your skin or whites of your eyes, called jaundice
• constant sore throat
• fever

Doctors usually treat pregnant and breastfeeding women with antithyroid medicine, since this treatment may be safer for the baby than other treatments.

Radioiodine therapy

Radioactive iodine is a common and effective treatment for hyperthyroidism. In radioiodine therapy, you take radioactive iodine-131 by mouth as a capsule or liquid. The radioactive iodine slowly destroys the cells of the thyroid gland that produce thyroid hormone. Radioactive iodine does not affect other body tissues.

You may need more than one radioiodine treatment to bring your thyroid hormone levels into the normal range. In the meantime, treatment with beta blockers can control your symptoms.

Almost everyone who has radioactive iodine treatment later develops hypothyroidism because the thyroid hormone-producing cells have been destroyed. However, hypothyroidism is easier to treat and causes fewer long-term health problems than hyperthyroidism. People with hypothyroidism can completely control the condition with daily thyroid hormone medicine.

Doctors don’t use radioiodine therapy in pregnant women or in women who are breastfeeding. Radioactive iodine can harm the fetus’ thyroid and can be passed from mother to child in breast milk.

Thyroid surgery

The least-used treatment for hyperthyroidism is surgery to remove part or most of the thyroid gland. Sometimes doctors use surgery to treat people with large goiters or pregnant women who cannot take antithyroid medicines.

Before surgery, your doctor may prescribe antithyroid medicines to bring your thyroid hormone levels into the normal range. This treatment prevents a condition called thyroid storm—a sudden, severe worsening of symptoms—that can occur when people with hyperthyroidism have general anesthesia.

When part of your thyroid is removed, your thyroid hormone levels may return to normal. You may still develop hypothyroidism after surgery and need to take thyroid hormone medicine. If your whole thyroid is removed, you will need to take thyroid hormone medicine for life. After surgery, your doctor will continue to check your thyroid hormone levels.

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Physical Therapy Management

Preferred Practice Patterns:

• Impaired muscle performance
• Impaired joint mobility, motor function, muscle performance, and ROM associated with connective tissue dysfunction
• Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation
• Impaired aerobic capacity/endurance associated with deconditioning 

When Is a Medical Referral Required?

• Anytime a therapist discovers unusual swelling or enlargement (with or without pain), tenderness, hoarseness, or dysphagia they should refer out.
• If your patient experiences fever, rash, arthralgia, or other side effects of antithyroid drugs, notify their physician because it may be possible to use another form of treatment.

What Should I Monitor During Treatment Session?

• Vital Signs: This is especially important if the patient is an older adult, has CAD or previous hx of heart disease, or presents with signs of dyspnea, fatigue, tachycardia, and/or arrhythmia.
• Watch for signs of hypoparathyroidism such as muscular twitching, tetany, numbness, and tingling around mouth, fingertips, or toes if patient is post thyroidectomy. Hypoparathryoidism may result 1-7 days after thyroidectomy if there are complications during the surgery resulting in unintentional removal of part of the parathyroid glands.

Safety Precautions for Therapist

• When working with patients who have been given RAI, be aware their saliva is radioactive for 24 hours following their treatment. When working with these patients it is important to take the necessary precautions if the patient is coughing or expectorating.

Hyperthyroidism and Exercise

• Some patients with Graves’ disease suffer from heat intolerance, making exercising in a hot pool a contraindication to therapy. This patient would still be able to participate in aquatic therapy in a warm pool; given the patient’s body temperature is being monitored. Typically heat intolerance is associated with thyroid storm, and will normally not occur in clients attending therapy in outpatient settings.
• Hyperthyroidism is associated with exercise intolerance and reduced exercise capacity.
• Many patients with hyperthyroidism suffer from cardiopulmonary complications often leading to atrial fibriliation, CHF, and increased risk of a MI.
• 70% of people with hyperthyroidism develop proximal muscle weakness as a result of treatment, most often affecting the pelvis and thigh muscles
• Chronic periarthritis and calcific tendinitis are also associated with hyperthyroidism. They both tend to occur in the shoulder, causing limitations in a person’s ROM, which may progress and lead to adhesive capsulitis. Therapeutic interventions using ultrasound, joint mobilizations, stretching, and strengthening may be performed once the thyroid gland is regulated. Research suggest a 6 week treatment period using pulsed US for 15 minutes at 2.5 W/cm2 at a frequency of .89 MHz is associated with short term improvement in pain levels and quality of life in adults with calcific tendonitis.
• Graves’ disease is associated with a low bone mineral density (BMD) and has also been shown to be a risk factor for hip fractures

Differential Diagnosis

• Hyperparathyroidism
• Myasthenia gravis
• Psychological disorders (anxiety, panic attacks, or mood disorders)
• Thyroid Cancer
• Atrial Fibrilation
• Congestive Heart Failure.

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