CASE STUDY: CUSHING’S SYNDROME

Demographics: Patient is a 33 year old Caucasian female who is a middle school teacher.

Medical diagnoses: Asthma, Bursitis

Co-morbidities: Obese, Hypertension, Type II Diabetes

Previous treatments: Insulin pump for Diabetes, Corticosteroid use for the past 7 years for asthma,
Hypertension medication, Physical therapy for treatment of hip bursitis

Examination

Subjective: Tracey Smith reports to Function First, via direct access, for general muscle weakness and
low back pain. She has been having low back pain for a little over 4 months now. On a scale of 1-10, her
pain at best is a 3 and at worst is a 7. The general muscle weakness has been getting progressively worse
over the past month and is beginning to concern her. Mrs. Smith also reports having trouble making it
through her water aerobics class on Tuesday’s and Thursday’s. She says lately she has little interest in her
regular activities and has been experiencing fatigue without physical exertion. Patient was diagnosed with
type II Diabetes in her late 20’s and has been taking insulin regularly since her diagnosis. Mrs. Smith has
also been experiencing headaches more frequently at night over the past few weeks. She was treated at
Function First in 2013 for hip pain secondary to bursitis. After 4 weeks of conservative treatment, Mrs.
Smith’s pain was still present and she was referred to her back to her primary care physician where he
administered multiple corticosteroid injections. Patient also reports she has been taking inhaled
corticosteroids for the past 7 years. Lastly, Mrs. Smith reports having irregular menstrual cycles for the
past 2 years accompanied by unexplained weight gain in her
abdomen.

Goals: Patient would like to have little to no back pain. Patient

also would like to be able to increase her strength and
endurance in able to resume her normal Zumba classes twice a
week.

Observation: Pt presents with purple/pink stretch marks on

arms, abdomen, and thighs. Pt has multiple cuts and bruises on
her arms and hands with an explanation of having thin skin. Pt
is obese with noticeable fatty deposits in the upper back and
midsection.

Clinical Impression

Based on the information gathered from the subjective and

objective history, the primary hypothesis would be that this
patient is suffering from Cushing’s syndrome. The patient
complained of unusual fatigue, back pain, headaches, irregular
menstrual cycles, generalized weakness, and a recent lack of
interest in her normal hobbies/activities. Accompanied by objective findings of proximal weakness,
purple/pink stretch marks, multiple bruises, and noticeable fatty deposits, Cushing’s syndrome would be
the most probable diagnosis. We believe this patient would need to be referred to a medical doctor to
confirm the presence of Cushing's syndrome and for other treatment outside the scope of physical
therapy. This being said, this patient would be a great candidate for physical therapy and would benefit
from a muscular strengthening and endurance program.

Interventions. Mrs. Smith will benefit from continued skilled physical therapy, three times a week for
eight weeks, to address functional limitations such as weakness, aerobic endurance, and ability to
participate in her exercise classes. It has also been shown that those diagnosed with Cushing’s syndrome
may also suffer from Glucocorticoid-Induced Muscle Atrophy[9]. Signs of this muscle atrophy can be
seen in the proximal muscle weakness associated with Cushing’s. Physical therapy interventions to
address this issue should contain resistance and endurance training[9]. Resistance training should include
activities that support bone and muscle mass growth since osteoporosis is also an additional disease these
patients can face. Exercise dosage should be focused on increasing muscular strength and hypertrophy to
help fight off the affects of muscle atrophy. Some examples of resistance training exercises are wall push-
ups with a serratus press, wall squats, single leg stance, quadruped alternating upper/lower extremity
extension, bridging with a posterior pelvic tilt, and scapular retraction with a theraband. Endurance
exercises should also be incorporated to address the deconditioning affects of muscle atrophy. Endurance
exercises can also be geared towards community activities such as walking in a park, cycling, swimming
or water aerobics, and also running if it does not increase pain. Exercise prescription can be progressed
when there is an increase in strength noted by the treating therapist and the ability of the patient to tolerate
an increase in exercise without adverse reactions. In addition to physical therapy, patient was referred to
MD for further diagnostic testing to confirm Cushing’s syndrome.[1] After confirmation Cushing’s
syndrome, her primary care physician prescribed mifepristone to block the effects of cortisol on
tissues.[1] Her MD also reduced the dose of her corticosteroids being used to treat her asthma.[1][2]

Outcomes. Due to Mrs. Smiths high motivation to get back to her usual activities and get healthy, her
prognosis is very good. She responded well to her first treatment session, but did report increased
muscular fatigue during wall squats and while riding the recumbent bicycle for ten minutes. Patient
needed both verbal and tactile cueing when performing scapular stability exercises and wall squats. After
four weeks of conservative therapy and pharmacological treatment, proximal muscle strength and aerobic
capacity/endurance had both increased substantially. Over the remainder of her treatment sessions, she
was able to increase her strength and endurance enough so that she was able to partake in her weekly
water aerobics classes and could also go on much longer walks around her neighborhood without having
an excessive feeling of over exertion with minimal activity. Her back pain had also decreased to a 0/10 at
best and 2/10 at worst. Since starting her treatment and exercise prescription, she had notice a decrease in
her weight and she no longer felt depressed about going to and participating in her zumba class.
 CASE STUDY: ADDISON’S DISEASE
Examination

Subjective: Jack E. Robinson, a 21 year old Caucasian male who lives with his parents, reports to your
clinic with a chief complaint of gradual onset of weakness and fatigue, and pain in his knees. On a 0-10
scale, he states that the pain in his knees is at a 3/10 at best and a 6/10 at its worst. Jack works at United
Parcel Service (UPS) at night while attending the local community college during the day. His work
duties require him to lift boxes up to 60 lbs. by himself and he has been struggling to do so in recent
months, even becoming dizzy and nearly fainting a few times. He has used almost all of his sick days due
to feeling nauseous and vomiting while at work and occasionally before coming to work. He reported a
slight decrease in his weight and not being hungry nearly as often. He used to stop by the 24 hour Subway
for a sandwich every night after work, but only goes one or two times per week in recent months. Now
when he goes the sandwiches taste bland and he has to use a lot of salt to make them taste better. He
states being nervous about eating certain foods when he is hungry due to diarrhea which he has not
figured out the cause of. When asked, he states that his tanned skin from the summer has not faded like it
usually does even though it is well into the winter months (January) and that he does not use a tanning
bed. He states his parents are worried because he is quick to become irritated with them and rarely comes
out of his room when at home.

Services: Jack has seen his primary care physician twice since the onset of symptoms and last time was
referred to PT with a prescription that said “evaluate and treat for weakness and fatigue”. He has received
no other care for his current condition.

Patient Goals: increase strength and stamina in order to return to peak performance levels at work and so
that workout regimen can resume.

Clinical Impression. Based on the information gathered from the subjective and objective history, the
primary hypothesis would be that this patient is suffering from Addison’s disease. The patient complained
of unusual fatigue, weakness, frequent diarrhea, a craving of salty foods, decreased appetite, joint pain,
and that his tan was lasting longer than usual. Accompanied by objective findings of generalized muscle
weakness, low blood sugar, hyperpigmentation of multiple areas of skin, and painful joints during
palpation, Addison’s disease would be the most probable diagnosis. We believe this patient would need to
be referred to a medical doctor to confirm the presence of Addison's disease and for other treatment
outside the scope of physical therapy. This being said, this patient would be a great candidate for physical
therapy and would benefit from a muscular strengthening and endurance program.

Summarization of Examination Findings. Patient displays generalized muscle weakness, weight loss
due to a decrease in appetite, joint pain with palpation and movement, salt cravings, nausea, diarrhea,
vomiting, and dizziness. Aerobic exercise will be implemented to address generalized weakness and
fatigue. A strengthening program will also be implemented to address the generalized muscle weakness
and fatigue.
Intervention. It is recommended that Mr. Robinson attend physical therapy three times a week for six
weeks. Physical therapy interventions for Mr. Robinson will be focused on the generalized weakness and
fatigue he is experiencing. A strengthening program will be put into effect which will include open and
closed chain exercises as well as functional exercises geared toward his position at UPS. Exercise dosage
should be focused on increasing muscular strength and hypertrophy to help fight off the affects of
musclular weakness and fatigue. The strengthening program will include squats, chest press, shoulder
press, bicep and tricep curls, lunge matrix, weighted knee extension, TheraBand® resisted knee flexion,
and lifting weighted boxes onto shelves of different heights. He will also need an endurance program to
address the excessive fatigue he has been experiencing. This program will include treadmill
walking/running, cycling, swimming, and recreational sports as he progresses. A referral to a nutritionist
may be necessary to address his decrease in appetite and his fear of eating certain foods. This may also be
effective, along with the exercise, in decreasing his episodes of nausea, vomiting and diarrhea. The
therapist will also suggest going back to the MD to get more tests done to confirm a diagnosis of
Addison's and also prescribe medications and hormones that could get this disease under control while he
is at PT. The doctor will most likely prescribe replacement corticosteroids to control the symptoms. Mr.
Robinson may also need replacement hormones, such as hydrocortisone or prednisone, to make up for the
ones that his adrenal glands can no longer produce. He will need to be educated that these are most likely
going to have to be something he takes for life and this is a good way to manage his symptoms and to
make sure his condition does not worsen

Outcomes. Due to Mr. Robinson's young age, high motivation, and experience in physical therapy for his
ACL repair, his prognosis is very good. The first treatment session went well and Mr. Robinson was
surprised how much he was able to do without getting fatigued. The squats and weighted knee extensions
had to be discontinued due to knee pain but he was able to complete the lunge matrix. He will benefit
from continued skilled PT to continue to work on his functional exercises so that he may return to work
with little no fatigue. After 4 weeks of therapy, Mr. Robinson reports no pain in his knees. He has gone
back to work and feels confident in all his lifting responsibilities. He continues to feel fatigued, but states
that he is continuing to progress and is able to go longer distances on his walks and has progressed to
riding the bike for 20 minutes at a time. His nutritionist has him on a meal plan that has decreased his
nausea, vomiting and diarrhea and he has been eating his normal amount. The medications and hormones
his MD prescribed have helped with the pigment of his skin and also helped with his irritation at home
which has made his parents happy as well.