Gout

Name: Madiha Sayed Nagy.

ID: 51859

1
 Gout
Definition/Description

Gout.jpg

Gout is a metabolic disorder; however, because the clinical presentation

closely resembles arthritis, gout is also classified as a form of crystal-
induced arthritis. There are three main types of gout, all of which usually
begin monoarticularly at the first metatarsophalangeal joint and are
characterized by sudden pain, swelling, and redness.

Gout is caused by monosodium urate crystal deposition in tissues leading

to arthritis, soft tissue masses (i.e., tophi), nephrolithiasis, and urate
nephropathy. The biologic precursor to gout is elevated serum uric acid
levels (i.e., hyperuricemia).

Gout and pseudogout are the 2 most common crystal-induced

arthropathies. They are debilitating illnesses in which pain and joint
inflammation are caused by the formation of crystals within the joint
space.

Prevalence
Effects over 2 million people in the US

The most common crystalopathy (in the US)

Rarely seen in children (< 10% of all cases)

Predominantly seen in men (most common inflammatory disease in men

over age 30)

Peak incidence in the 4th - 5th decades of life

2
Frequency increases in postmenopausal women (lack of estrogen)

Characteristics/Clinical Presentation
There are four stages of gout, although diagnosis does not require the
presence or occurance of each stage. The four stages are:

1. Asymptomatic hyperuricemia ( serum urate > 7mg/dl)

2. Acute gouty arthritis

3. Intercritical gout

4. Chronic tophaceous gout

Asymtomatic hyperuricemia is the phase of gout prior to the first

attack, when serum urate levels are elevated but no symptoms are
present. [1]

Acute gouty arthritis is the most common clincial presentation

and is most often found (90%) at the first metatarsophalangeal
joint. Symptoms generally begin with a sudden onset of localized,
intense pain, often occuring at night. The pain may be great
enough to awaken the patient. Redness, extreme tenderness, and
swelling around the joint will occur within a few hours of the
initial pain. Hypersensitivity, chills, tachycardia, malaise, and
fever may also be present. The skin may also become red or
purplish, shiny, tense, and warm. ]

Occasionally, acute gouty arthritis can also occur at the fingers, wrist,
elbow, knee, ankle, and instep. Even more rarely, acute gouty arthritis
may present at the cervical spine, sternoclavicular joint, shoulder, hip,
and sacroilliac joint. The initial attack may last a few days to 2 weeks, if
left untreated. Attacks will recur; however time periods of months or
years may elapse between them. As the attacks recur, they will become
more intense and may spread to other joints in the body. A patient may
eventually exprience several attacks per year

3
Presentation of acute gout at the PIP joint Presentation of acute gout at the olecranon

The intercritical phase occurs after recovery from each episode.

This phase is asymtomatic and may last for months to years at a
time. It is important to note that although this is an aysmptomatic
stage, serum urate levels are often still elevated and urate crystals
may still be present.

As the gout attacks continue, tophi will develop in the joints,

tendons, bursae, subchondral bone, cartilage, ligaments,
subcutaneous tissue, and synovium. Tophi are hard nodules of
sodium urate deposits that may vary in number and location.
Although typically a painless structure, the formation of tophi can
cause an acute inflammatory response within the tissue. As the
tophi become enlarged they may cause deformities, and there is
potential for them to protrude through the skin and exude a white
chalky substance (urate crystals). Some of the most common sites
of enlarged tophi are the forearm, ear, knee and foot.

Note: Prior to the use of urate-lowering drugs for the treatment of

acute gouty arthritis, tophi developed in approximately 30 - 50% of
patients.

Urate Crystals removed from tophi

Chronic tophaceous gout is characterized by increased pain,

deformity (from tophi), decreased ROM, and subsequent functional
loss. Due to the treatments used for gout today, chronic tophaceous
gout is rare.
4
Medications

NSAIDS, Corticosteroids, or COX-2 inhibitors: for pain and

inflammation management during an acute attack

Allopurinol: to slow the rate of uric acid production and help

prevent future attacks

Cholchicine: occasionally used in the acute phase; however, use is

less common due to frequency of side effects and narrow
therapeutic range

Supplementary analgesics

Probenecid and sulfinpyrazone may be used to lower serum urate

levels

Diagnostic Tests/Lab Tests/Lab Values

Arthrocentesis and synovial fluid analysis: should be performed

upon initial presentation. Positive results include: identification of
needle shaped bifringent urate crystals that are engulfed by
phagocytes or free floating; 2,000 - 100,000 WBCs/uL with over
half of the WBCs as polymorphonuclear.

Gram stain and culture: to rule out infectious arthritis

Elevated serum urate levels may support diagnosis but are not
sensitive or specific. Levels should be measured on several
different occasions and it is possible for levels to be normal during
and actute attack. Elevated levels are considered to be greater than
7mg/dL

24 hour urate excretion: normal is 600-900 mg. This may help

identify hyper production of uric acid or decreased excretion.[2]

X-rays: to examine tophi. X-rays are not essential for diagnosis.

5
X-ray gout.jpg

Causes
There are three types of hyperuricemia based on cause:

1. Primary hyperuricemia is an inherited form of the disorder.

2. Idiopathic hyperuricemia does not have a known cause.

3. Secondary hyperuricemia can result from a variety of causes

including:

renal dysfunction or disease (hemodialysis, polycystic kidney

disease, renal insufficiency)

leukemia, lymphomas, psoriasis

hematopoetic disorders (hemolytic anemia, myeloma,

polycythemia vera, myeloproliferative disorder)

chemotherapy agents

obesity, fasting

medications (diuretics, salicylates, levodopa, cyclosporine, low

dose asprin, vitamin B12)

heavy alcohol consumption

hypertension

endocrine disorders: (hyperparathyroidism, hypoparathyroidism,

hyperthyroidism, diabetes mellitus)

6
 a diet rich in purines (shellfish, organ meats, beans, spinach, etc.)

medical stressors (surgery, trauma, infection, etc.)

fatigue or emotional stress [2]

toxemia of pregnancy, hyperlipidemia, chondrocalcinosis

?What are complications of gout

Gout can cause joint pain and stiffness and can also lead to chronic
progressive damage to joint cartilage and bone. It can also lead to the
accumulation of "clumps" of uric acid (tophi) in body tissues that can
cause local injury to the body areas affected. Gout can also lead to kidney
.stones and elevated blood pressure (hypertension)

Medical Management (current best evidence)

There are three main goals of the medical management of gout:

1. Terminate acute attacks

2. Prevent recurrance

3. Correct and prevent further damage from hyperuricemia

Termination of acute attacks - NSAIDs are the most common and

generally effective treatment for acute attacks. Cox-2 inhibitors are often
the second choice for those who develop GI toxicity; however, they
should be used with great caution with any patient with a history of CV
complications or co-morbidities. Intraarticular corticosteroid injection
may also be effective for the management of an acute attack. Colchicine
may also be used either po or by IV and may produce substantial pain
relief if started immediately after onset of symptoms. Supplementary
analgesics may also be recommended along with rest, elevation, and joint
protection strategies.

Prevention of recurrance - Daily low doses of NSAIDs or Cholcicine are

commonly used to prevent recurrent attacks.

7
Correction and prevention of hyperuricemia - Uricosuric drugs or
allopurinol may be used alone or in conjunction. Hypouricemic therapy
may also be used for patients with tophi and a higher recurrance rate.
Dietary restriction of high-purine foods is a less effective treatment
technique but is still recommended. Carbohydrate restrictions may also
be helpful. Other treatment possibilties include hydration greater than 3
liters per day. Alkalinization of urine, extracorporeal shock wave
lithotripsy, and surgical excision may also be beneficial.

Physical Therapy Management (current best

evidence)
Physical therapy management of gout falls under preferred practice
pattern 4E: Impaired joint mobility, motor function, muscle performance,
and range of motion associated with localized inflammation.

The physical therapist should be aware that any patient with a history of
gout, hyperuricemia, and/or a septic joint presentation should be refered
for medical evaluation prior to treatment.

During acute exacerbations the physical therapist should focus on

reinforcement of management program and splinting, orthotics, or other
assistive devices to protect the affected joint(s).

A 2002 study in the Journal of Rheumatology found that the use of

cryrotherapy to alleviate the pain associated with acute bouts of gout may
be effective.

During intercritical phases physical therapists may offer assistance with

maintinance of ROM, strength, and function. The physical therapist can
also assist the patient in the creation of a suitable exercise routine and
keeping thier weight under control.

There is a Randomized Clinical Trial which suggests that

Electroacupuncture in combination with blood letting puncture and
cupping has relatively good results as a treatment for Gout. The treatment
is effective mostly because the blood uric acid decreased significantly
after the treatment was given to the patients.

There is another study about Electroacupuncture combined with local

blocking therapy on acute gouty arthritis that shows an improvement in

8
health status of the patients. This treatment is positive and it also
decreases blood uric acid levels.

Exercises
One of the best ways to prevent kidney stones and the recurrence of gout
is to exercise. Aside from helping you stay in shape and maintaining a
healthy body weight, exercise provides your body with many benefits,
some of which include:

-Strengthening, building and maintaining healthy bones, muscles and

joints - Improve mobility and flexibility
- Improves circulation
- Reduces the risk of heart disease and premature death
- Reduces the risk of cancer
- Reduces the risk of developing diabetes
- Reduces the risk of high cholesterol and lowers high cholesterol
- Reduces stress and improves your mental state of mind
- Gives you more energy

Stretching Exercises
Stretching increases flexibility in your body, and a physical therapist will
have you engage in moderate exercises to reduce stiffness and increase
circulation. Performing simple stretches, such as knee bends, helps
relieve tension in the joints and reduce inflammation. Knee bends are
done by leaning over, with a slight bend in your knees, and attempting to
touch your toes. Some physical therapists recommend performing range-
of-motion exercises that are involved in yoga, tai chi and pilates.

Endurance Program

A physical therapist will have you begin endurance exercises to improve

blood circulation, heart function and relieve symptoms of gout. Because
gout often attacks your feet, it's important to engage in low-impact
exercises that won't put any additional strain on your lower extremities.
Physical therapy will include a swimming or stationary cycling program

9
that can be easily monitored by a therapist. As your condition improves,
the exercises will become more strenuous.

Strength Program

Strengthening exercises condition and tone your muscles, which give you
healthy and strong joints. Physical therapy involves using light dumbbells
to perform simple leg exercises, such as squat and lunges. These
exercises promote circulation in your legs and feet and prevent joints
from becoming inflamed.

Hold a pair of dumbbells at your sides, and bend your knees while
keeping your back straight. Bend you knees until your hamstrings are
parallel with the ground and then slowly stand up.

Lunges are started in the same manner, but instead of bending down take
a step forward. While keeping your upper body vertical, lean your front
leg forward until your back knee is just off the ground. Take a step back
and repeat with the other leg. A physical therapist will recommend the
proper weights and repetitions and ensure you are performing the
exercises with the correct form.

Water Aerobics
Working out in the water can help gout sufferers in several ways. First,
the natural resistance that water creates helps to amp up your workout
without requiring increased pressure or impact on your joints. Second, the
buoyancy of water can help reduce the strain on your joints created by
your body weight.
"Arthritis Today" magazine notes that many gyms offer underwater
walking classes using aquatic treadmills. Even if your local gym doesn't
offer such high tech amenities, many gyms and community centers offer
basic water aerobics classes that may focus on swimming, aquatic tai chi
or yoga or simply walking around the shallow end of the pool.

Cardio Exercise

10
Cardiovascular, or aerobic, exercise increases heart rate, promoting more
oxygen flow to the body. It also helps to burn calories, promoting weight
loss.
Because gout often attacks the big toe and foot areas, talk to you doctor
before engaging in aerobic exercise. High impact aerobics and other
activities may aggravate your symptoms. Lower impact exercises, like
swimming, may be better for your particular case.

Gout diet

Dietary changes can help reduce uric acid levels in the blood. Since
purine chemicals are converted by the body into uric acid, purine-rich
foods are avoided. Examples of foods rich in purines include shellfish and
organ meats such as liver, brains, kidneys, and sweetbreads. Researchers
have reported, in general, that meat or seafood consumption increases the
risk of gout attacks, while dairy food consumption seemed to reduce the
risk. Protein intake or purine-rich vegetable consumption was not
associated with an increased risk of gout. Total alcohol intake was
strongly associated with an increased risk of gout (beer and liquor were
particularly strong factors). Fructose from the corn syrup in soft drinks
also increases the risk of gout. It should be noted that even the best diet
that avoids foods and beverages that increase the risk of gout will only
lower blood uric acid level by 1 mg/dL.

Weight reduction can be helpful in lowering the risk of recurrent attacks

of gout. This is best accomplished by reducing dietary fat and calorie
intake, combined with a regular aerobic exercise program.

Differential Diagnosis
Pseudogout - a form of arthritis that occurs 1/8th as often as gout.
Symptoms are very similar to gout; however, the knee joint is primarily
affected. Diagnosis is made by aspiration of synovial fluid.

11
Other differential diagnosis include RA, neoplasm, septic arthritis,
infectious arthritis, acute rheumatic fever, juvenile RA, acute fracture,
and palindromic rheumatism.

Acute gouty arthritis typically presents with rapid development of severe

joint pain, swelling, and tenderness that reaches its maximum within just
6-12 h, especially with overlying erythema, most classically in the first
metatarsophalangeal joint. Demonstrating the presence of monosodium
urate (MSU) crystals in the joint fluid or tophus has been the gold
standard for the diagnosis of gout.

References
1. https://www.physio-pedia.com/Gout

2. http://www.ipcphysicaltherapy.com/GoutArthiritis.aspx

3. Goodman CC, Fuller KS. Pathology: Implications for the Physical

Therapist. 3rd ed. Saint Louis, MO: Saunders; 2009.

4. Beers MH, et. al. eds. The Merck Manual of Diagnosis and
Therapy. 18th ed. Whitehouse Station, NJ: Merck Research
Laboratories; 2006.

5. Goodman C, Snyder T. Differential Diagnosis for Physical

Therapists: Screening for Referral. St. Louis, Missouri: Saunders
Elsevier, 2007.

6. Wheeless, C R. Pseudogout and Chondrocalcinosis. Wheeless'

Textbook of Orthopaedics. November 2008.

12