World Journal of Surgery

, Volume 38, Issue 3, pp 549–557 | Cite as

Muscle Function Is Impaired in Patients With “Asymptomatic” Primary Hyperparathyroidism

  • Lars Rolighed
  • Anne Kristine Amstrup
  • Niels Frederik Breum Jakobsen
  • Tanja Sikjaer
  • Leif Mosekilde
  • Peer Christiansen
  • Lars Rejnmark



Patients with “asymptomatic” primary hyperparathyroidism (PHPT) often describe improvement after surgery.


We evaluated muscle and balance function, quality of life (QoL), and well-being in 58 PHPT patients and 58 population-based matched controls in a cross-sectional study. We tested whether patients considered “asymptomatic” according to international guidelines have functional impairment.


Mean age of the patients and controls was 59 years, and 47 (81 %) were women. Patients had higher levels of plasma PTH and ionized calcium. Creatinine and 25-hydroxyvitamin D levels did not differ between groups. Altogether, 16 (28 %) patients were “asymptomatic.” Compared with controls, PHPT was associated with significantly lower QoL in all eight domains of the short form-36 questionnaire, lower well-being (WHO Five Well-Being Index; p < 0.001), and impaired postural stability during normal standing with eyes open (p < 0.05) or closed (p < 0.001). Maximum isometric muscle strength was reduced in both upper (p < 0.01) and lower (p < 0.001) extremities. Physical performance was decreased during 10 repeated chair stands (p < 0.001) and time to walk 3 m forward and back (p < 0.05). Restricting analyses to “asymptomatic” patients showed significantly lower muscle strength at knee extension and flexion and impaired postural stability than in matched controls.


PHPT is associated with deleterious effects on muscles and QoL. Impairments also apply to patients with mild disease, normally considered “asymptomatic.” This may explain why “asymptomatic” patients report improvements following surgery. The impaired muscle function may contribute to increased fracture risk independent of bone mineral density.


  1. 1.
    Bollerslev J, Marcocci C, Sosa M et al (2011) Current evidence for recommendation of surgery, medical treatment and vitamin D repletion in mild primary hyperparathyroidism. Eur J Endocrinol 165:851–864PubMedCrossRefGoogle Scholar
  2. 2.
    Bilezikian JP (2012) Primary hyperparathyroidism. Endocr Pract 18:781–790PubMedCrossRefGoogle Scholar
  3. 3.
    Pemberton JDJ, Geddie KB (1930) Hyperparathyroidism. Ann Surg 92:202–211CrossRefGoogle Scholar
  4. 4.
    Bilezikian JP, Potts JT Jr, Fuleihan G et al (2002) Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Clin Endocrinol Metab 87:5353–5361PubMedCrossRefGoogle Scholar
  5. 5.
    Silverberg SJ, Lewiecki EM, Mosekilde L et al (2009) Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 94:351–365PubMedCrossRefGoogle Scholar
  6. 6.
    Morris GS, Grubbs EG, Hearon CM et al (2010) Parathyroidectomy improves functional capacity in “asymptomatic” older patients with primary hyperparathyroidism: a randomized control trial. Ann Surg 251:832–837PubMedCrossRefGoogle Scholar
  7. 7.
    Perrier ND, Balachandran D, Wefel JS et al (2009) Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with “asymptomatic” primary hyperparathyroidism. Surgery 146:1116–1122PubMedCrossRefGoogle Scholar
  8. 8.
    Deutch SR, Jensen MB, Christiansen PM et al (2000) Muscular performance and fatigue in primary hyperparathyroidism. World J Surg 24:102–107. doi:10.1007/s002689910019 PubMedCrossRefGoogle Scholar
  9. 9.
    Jansson S, Grimby G, Hagne I et al (1991) Muscle structure and function before and after surgery for primary hyperparathyroidism. Eur J Surg 157:13–16PubMedGoogle Scholar
  10. 10.
    Hedman I, Grimby G, Tisell LE (1984) Improvement of muscle strength after treatment for hyperparathyroidism. Acta Chir Scand 150:521–524PubMedGoogle Scholar
  11. 11.
    Quiros RM, Alef MJ, Wilhelm SM et al (2003) Health-related quality of life in hyperparathyroidism measurably improves after parathyroidectomy. Surgery 134:675–681 discussion 681–683PubMedCrossRefGoogle Scholar
  12. 12.
    Weber T, Eberle J, Messelhauser U et al (2012) Parathyroidectomy, elevated depression scores, and suicidal ideation in patients with primary hyperparathyroidism: results of a prospective multicenter study. Arch Surg 15:1–7Google Scholar
  13. 13.
    Amstrup AK, Rejnmark L, Vestergaard P et al (2011) Vitamin D status, physical performance and body mass in patients surgically cured for primary hyperparathyroidism compared with healthy controls: a cross-sectional study. Clin Endocrinol (Oxf) 74:130–136CrossRefGoogle Scholar
  14. 14.
    Amstrup AK, Rejnmark L, Mosekilde L (2011) Patients with surgically cured primary hyperparathyroidism have a reduced quality of life compared with population-based healthy sex-, age-, and season-matched controls. Eur J Endocrinol 165:753–760PubMedCrossRefGoogle Scholar
  15. 15.
    Jakobsen NF, Rolighed L, Nissen PH et al (2013) Muscle function and quality of life is not impaired in familial hypocalciuric hypercalcemia (FHH): a cross-sectional study on physiological effects of inactivating variants in the calcium sensing receptor gene (CaSR). Eur J Endocrinol 169:349–357PubMedCrossRefGoogle Scholar
  16. 16.
    Maunsell Z, Wright DJ, Rainbow SJ (2005) Routine isotope-dilution liquid chromatography-tandem mass spectrometry assay for simultaneous measurement of the 25-hydroxy metabolites of vitamins D2 and D3. Clin Chem 51:1683–1690PubMedCrossRefGoogle Scholar
  17. 17.
    Curb JD, Ceria-Ulep CD, Rodriguez BL et al (2006) Performance-based measures of physical function for high-function populations. J Am Geriatr Soc 54:737–742PubMedCrossRefGoogle Scholar
  18. 18.
    Ambrogini E, Cetani F, Cianferotti L et al (2007) Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial. J Clin Endocrinol Metab 92:3114–3121PubMedCrossRefGoogle Scholar
  19. 19.
    Bollerslev J, Jansson S, Mollerup CL et al (2007) Medical observation, compared with parathyroidectomy, for asymptomatic primary hyperparathyroidism: a prospective, randomized trial. J Clin Endocrinol Metab 92:1687–1692PubMedCrossRefGoogle Scholar
  20. 20.
    Rao DS, Phillips ER, Divine GW et al (2004) Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism. J Clin Endocrinol Metab 89:5415–5422PubMedCrossRefGoogle Scholar
  21. 21.
    De Wit M, Pouwer F, Gemke RJ et al (2007) Validation of the WHO-5 Well-Being Index in adolescents with type 1 diabetes. Diabetes Care 30:2003–2006PubMedCrossRefGoogle Scholar
  22. 22.
    Arthur ST, Cooley ID (2012) The effect of physiological stimuli on sarcopenia: impact of Notch and Wnt signaling on impaired aged skeletal muscle repair. Int J Biol Sci 8:731–760PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Mosekilde L (2008) Primary hyperparathyroidism and the skeleton. Clin Endocrinol (Oxf) 69:1–19CrossRefGoogle Scholar
  24. 24.
    Holick MF (2012) Vitamin D: extraskeletal health. Rheum Dis Clin North Am 38:141–160PubMedCrossRefGoogle Scholar
  25. 25.
    Bolland MJ, Grey AB, Orr-Walker BJ et al (2008) Prospective 10-year study of postmenopausal women with asymptomatic primary hyperparathyroidism. N Z Med J 121:18–29PubMedGoogle Scholar
  26. 26.
    Khan A, Grey A, Shoback D (2009) Medical management of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 94:373–381PubMedCrossRefGoogle Scholar
  27. 27.
    Bilezikian JP, Khan AA, Potts JT Jr (2009) Third international workshop on the management of asymptomatic primary hyperthyroidism: guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab 94:335–339PubMedCrossRefGoogle Scholar
  28. 28.
    Cetani F, Pardi E, Borsari S et al (2011) Molecular pathogenesis of primary hyperparathyroidism. J Endocrinol Invest 34(Suppl):35–39PubMedGoogle Scholar
  29. 29.
    Reppe S, Stilgren L, Abrahamsen B et al (2007) Abnormal muscle and hematopoietic gene expression may be important for clinical morbidity in primary hyperparathyroidism. Am J Physiol Endocrinol Metab 292:E1465–E1473PubMedCrossRefGoogle Scholar
  30. 30.
    Smock SL, Vogt GA, Castleberry TA et al (2001) Molecular cloning and functional characterization of the canine parathyroid hormone/parathyroid hormone related peptide receptor (PTH1). Mol Biol Rep 28:235–243PubMedCrossRefGoogle Scholar
  31. 31.
    Ward BK, Magno AL, Walsh JP et al (2012) The role of the calcium-sensing receptor in human disease. Clin Biochem 45:943–953PubMedCrossRefGoogle Scholar
  32. 32.
    Vestergaard P, Mollerup CL, Frokjaer VG et al (2000) Cohort study of risk of fracture before and after surgery for primary hyperparathyroidism. BMJ 321:598–602PubMedCrossRefGoogle Scholar
  33. 33.
    Yoshimura N, Oka H, Muraki S et al (2011) Reference values for hand grip strength, muscle mass, walking time, and one-leg standing time as indices for locomotive syndrome and associated disability: the second survey of the ROAD study. J Orthop Sci 16:768–777PubMedCrossRefGoogle Scholar
  34. 34.
    Harbo T, Brincks J, Andersen H (2012) Maximal isokinetic and isometric muscle strength of major muscle groups related to age, body mass, height, and sex in 178 healthy subjects. Eur J Appl Physiol 112:267–275PubMedCrossRefGoogle Scholar
  35. 35.
    Janssen I, Heymsfield SB, Ross R (2002) Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 50:889–896PubMedCrossRefGoogle Scholar
  36. 36.
    Rolighed L, Vestergaard P, Heickendorff L et al (2013) BMD improvements after operation for primary hyperparathyroidism. Langenbecks Arch Surg 398:113–120PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Lars Rolighed
    • 1
  • Anne Kristine Amstrup
    • 2
  • Niels Frederik Breum Jakobsen
    • 2
  • Tanja Sikjaer
    • 2
  • Leif Mosekilde
    • 2
  • Peer Christiansen
    • 3
  • Lars Rejnmark
    • 2
  1. 1.Department of Surgery PAarhus University HospitalAarhus CDenmark
  2. 2.Department of Endocrinology and Metabolism MEAAarhus University HospitalAarhusDenmark
  3. 3.Department of Surgery P, Breast and Endocrine SectionAarhus University HospitalAarhusDenmark

Personalised recommendations