Hashimoto's Thyroiditis Case Study

Original Editor - Kerri Falk

Top Contributors - Kerri Falk and Rucha Gadgil  

Abstract

Hashimoto’s thyroiditis is an autoimmune disease. Hashimoto’s thyroiditis is often associated with arthralgia, myalgia, can lead to myopathy. Physical therapy can assist with the neuromuscular and musculoskeletal materializations that are seen in many patients with the condition. Physical therapy emphasis is on restoring the secondary effects of the disease such as restoration of joint range of motion, alleviation of pain in joints and muscles, and restoring strength due to muscle weakness. This case study depicts what may be seen in a patient coming to Physical therapy with Hashimoto’s thyroiditis as well as clinical impression, interventions, and outcomes.

Introduction

Hashimoto’s thyroiditis was first discovered in 1912 by Japanese physician Hakaru Hashimoto (1881−1934). Hashimoto's thyroiditis or chronic lymphocytic thyroiditis is an organ specific autoimmune disease in which the thyroid gland is attacked by cell and antibody mediated responses. Hashimoto’s is the most common cause of hypothyroidism in the United States. Incidence is estimated to be 3.5 per 1000 per year in women and 0.8 per 1000 per year in men, or 1-2% of the population. The disease slowly can progress over time into thyroid deficiency. Musculoskeletal and neuromuscular manifestations can occur at any time during the disease process. According to a study by Cakir M, Samanci N, Balci N, Balci MK adhesive capsulitis, Dupuytren’s contracture, trigger finger, limited joint mobility and carpal tunnel syndrome have all been found in patients with hypothyroidism. 

Case Presentation

Susan is a 46 year old elementary school teacher. She reports that she has been feeling more fatigued over the last couple of months compared to previously. She attributed it to beginning a new school year. Susan complains of feeling overall muscle aches and stiffness especially at her neck during that time that was not progressed or lessened. It has not been relieved with ibuprofen or heat. Patient has a tender palpable mass on the anterior aspect of her neck. Personal and familial history of hypothyroidism. Cervical and thoracic ROM limited in several directions.

• Medical diagnosis: hypothyroidism 3 years prior
• Co-morbidities: hypertension, Type 2 diabetes mellitus
• Past medical history: ACL reconstruction when she was twenty.
• Family medical history: grandmother had hypothyroidism. Father had an MI at approximately 55 years old.
• Medications/supplements: lisinopril (anti-hypertensive); multi-vitamin, synthroid
• Previous physical therapy treatment: Following ACL reconstruction approximately twenty years ago. Treatment for adhesive capsulitis 4 years prior.
• Self-reported outcomes: Neck Disability Index: 64%; Canadian Occupational Performance Measure unremarkable.
• Physical performance outcomes: 5 times sit to stand 11.2 seconds; continuous scale- physical functional performance 63%
• Objective: Upon palpation of anterior neck there was the presence of a painful, palpable mass. Upper quarter screen: C4/5 weakness bilaterally. Remaining myotomes and dermatomes were within normal limits. Positive Phalen’s test and positive Tinel’s sign.
• ROM: Cervical flexion limited to 10 degrees. Cervical extension 35 degrees. Left cervical rotation 26 degrees. Thoracic spine flexion limited to 10 degrees. Side bending bilaterally limited to 15 degrees each side. Remaining upper quarter ROM WNL.

Clinical Impression

• Increased fatigue
• Overall muscle aches and stiffness in neck not lessening
• Palpable tender mass in anterior neck
• C4/5 weakness bilaterally
• Cervical flexion limited to 10^o
• Cervical extension limited to 35^o
• Left cervical rotation limited to 26^o
• Thoracic spine flexion 10^o
• Bilateral cervical side bending 15^o
• NDI 64%
• Physical function performance 63%
• Known systemic problem (Hypothyroidism and Diabetes Mellitus type II)
• Bilateral Carpal Tunnel Syndrome

Intervention

Referred patient to her PCP for follow up and called physician to discuss findings
Discussed POC with patient 2x week for 4 weeks

• Patient education regarding posture and sleeping mechanics
• Postural retraining of the cervical spine
• Ergonomic training
• Strengthening exercises of trunk and postural back muscles
• Postural stability training of the postural back muscles
• Core stabilization exercises
• Stretching exercises for the wrist and hands
• Nerve gliding of the median nerve
• Tendon glide exercises

Outcomes:

The Anti-thyroid Antibody test run on Susan showed she was positive for the antibodies indicating she was experiencing Hashimoto’s thyroiditis. Her doctor changed her Synthroid dose and referred her back to physical therapy for treatment of carpal tunnel. After having her medication dosage changed coupled with the physical therapy she received for her carpal tunnel symptoms, Susan was able to increase her range of motion:
45^o cervical extension
20^o cervical flexion
50^o cervical rotation
25^o cervical side-bending bilaterally
25^o spine flexion
The goiter in her neck prevented her from achieving more range of motion in her neck.

Discussion

There is limited research on physical therapy to treat Hashimoto’s thyroiditis, however, Physical therapists are able to treat the musculoskeletal impairments secondary to the disease. Recent studies show it is not uncommon for persons with hypothyroidism to have carpal tunnel syndromeamong other musculoskeletal impairments. Physical therapist discretion must be used and thorough differential diagnosis must be performed in order to carefully screen for rheumatic and certain neurological diseases which are a contraindication for manipulation. More research must be performed in the area of how physical therapy can assist patients who are experiencing musculoskeletal impairments secondary to hypothyroid dysfunction.