| Gout is a metabolic disease in which uric acid crystals accumulate in one or more joints, leading to inflammation, swelling, severe pain, and arthritis. Gout tends to involve joints of the lower extremities: the great toe is affected most often, in about 50% of patients, followed by the instep, ankle, and heel. The wrists, elbows, and fingers may also be affected. Over time, deposits of uric acid crystals may cause deformity of the joints.
In addition to acute inflammatory arthritis, other manifestations of gout may include deposits of sodium biurate (tophi) in soft tissues and/or in the kidney (renal tophi); and/or urinary stones (urolithiasis). Although chronic elevation of uric acid in the blood (hyperuricemia) is necessary for the development of gout, other factors are also important, and most individuals with elevated uric acid levels do not develop gout.
Either an overproduction or an under-excretion of uric acid may cause gout. Most attacks occur without an apparent cause, but occasionally an attack may follow an operation, infection, trauma, or dietary/alcoholic overindulgence.Risk: In susceptible individuals, there is an increased risk of a gout attack with alcohol consumption; starvation; over indulgence in foods with high purine content, such as organ meats and oily fish; ingestion of drugs that cause changes in urate concentration; or with minor trauma. Incidence and Prevalence: It is estimated that more than 1 million Americans are affected by gout. Researchers estimate prevalence at 1% of the US population (Francis). Initial attacks of gout most often occur between the ages of 40 and 60 years. Males are affected by gout more than females. The prevalence is 13.6 cases per 1000 for men, and 6.4 cases per 1000 for women (Francis). The number of postmenopausal women with gout is increasing, however (Matsen). |
Source: Medical Disability Advisor
| History: The individual may complain of the sudden onset of a red, hot, swollen, and exquisitely tender joint; pain is usually limited to one joint but occasionally occurs in multiple joints. Often the pain begins at night and is severe enough to wake the individual from sleep. Some individuals may report that the pain disappears after a few hours while others may have pain that lasts for several weeks. The individual may report that the pain disappears spontaneously and then returns after a period of months. Physical exam: Findings on physical exam may include a reddened, warm, swollen, tender joint. Pain is elicited with slight pressure. However, the physical exam may be normal if the individual does not seek treatment during an acute attack. If the individual has had high levels of uric acid over many years, he or she may also have crystal deposits in the soft tissues of the ears, hands, feet, and elbows (tophi). Tests: Diagnosis involves aspiration of the joint (arthrocentesis) with microscopic examination for urate crystals, or tissue biopsy for evaluation of sodium biurate deposits (tophi). Sedimentation rate, complete blood count (CBC), and a 24-hour urine collection are done to assess uric acid levels. X-rays of the involved joint may be done to rule out other conditions. A bone scan or MRI may be used to detect all areas involved. |
Source: Medical Disability Advisor
| Medications are the mainstay of treatment. During an acute attack, these may include non-steroidal anti-inflammatory agents and a specific anti-gout agent called colchicine. The individual's response to colchicine may be used for diagnosis as well as treatment. During an acute attack, the affected joint(s) should be kept at rest. Corticosteroids may be used in individuals who are not able to take non-steroidal anti-inflammatory agents (NSAIDs) or colchicine.
In chronic gout, medications that increase the excretion of uric acid in the urine (uricosuric agents) and those that block the production of uric acid (allopurinol) are used. Most individuals are urged to limit their consumption of organ meats and alcohol because both interfere with the elimination of uric acid. Weight loss is recommended for obese individuals in order to ease the strain on affected joints. |
Source: Medical Disability Advisor
| It is important to begin treatment when symptoms of an acute attack first appear. Lifelong medications to increase the excretion of uric acid in the urine (uricosuric agents) and block the production of uric acid (allopurinol) are usually effective. Kidney damage may occur in up to 10% of individuals with gout. |
Source: Medical Disability Advisor
| In general, rehabilitation recommendations for those with gout are similar to individuals with other forms of arthritis. Individuals who suffer from complications of joint deformity and immobility may benefit from outpatient physical therapy for range of motion exercises, to control pain and inflammation, and to increase flexibility. A typical frequency and duration is 2 times per week for 4 weeks.
Therapists instruct individuals in the application of heat to decrease joint stiffness and pain. Individuals learn to apply heat for fifteen minutes as needed for pain control. Therapists instruct in gentle stretching and strengthening exercises for the affected joints. Individuals learn to perform these exercises independently to help reduce impairment due to joint stiffness and deformity. Individuals also perform low-impact aerobic exercise such as walking or swimming to increase strength and endurance, and decrease fatigue. Individuals who suffer from gait abnormalities may be trained to walk with a cane to decrease stress through the foot and toes. Individuals who are unable to perform exercises due to pain may benefit from an aquatic therapy program in a heated pool, which reduces the stress through an individual's joints due to the buoyant properties of water.
Occupational therapy may be needed to address activities of daily living such as dressing and bathing. Individuals learn to modify activities to preserve their joints during dressing, by first laying out their clothes and then sitting down to dress. Individuals may need to shower while sitting on a tub seat due to lower extremity joint pain and may need to use a long-handled sponge to reduce stress on upper extremity joints. For those individuals who have arthritis in the fingers, wrist and hand, occupational therapists can order adaptive equipment such as jar-openers, utensils with thicker handles, and elastic shoelaces, to decrease stress that these joints experience in daily activities. Other energy and joint conservation methods, such as allowing dishes to soak for a while to decrease the effort required to wash the dishes or distributing the weight evenly in grocery bags, may also be taught in occupational therapy to help an individual reduce fatigue and joint stress. |
Source: Medical Disability Advisor
| Complications include death of bone tissue due to insufficient blood supply (necrosis), bone deformity, kidney damage, chronic arthritis, and high blood pressure (hypertension). |
Source: Medical Disability Advisor
| Most individuals will require sick leave during an acute attack. If the person continues to work, temporary assignment to sedentary duties may be required. Reassignment may be necessary for individuals whose jobs require prolonged standing or walking. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Was diagnosis of gout confirmed through aspiration of the joint (arthrocentesis) with microscopic examination for urate crystals or by tissue biopsy for evaluation of sodium biurate deposits (tophi)?
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Were a sedimentation rate, complete blood count (CBC) with differential, and a 24-hour urine collection to assess uric acid levels done?
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Were x-rays of the involved joint done to rule out other conditions with similar symptoms?
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Does individual have any coexisting conditions that may complicate treatment or impact recovery?
Regarding treatment:
- Has individual been placed on appropriate medications such as anti-inflammatory agents or anti-gout medications?
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Has drug therapy included the use of medications to lower the uric acid levels?
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Has the individual been instructed to follow a diet low in purines? Would individual benefit from consultation with a nutritionist?
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If appropriate, has individual been instructed to lose weight? Would individual benefit from enrollment in a community weight loss program?
Regarding prognosis:
- Did the individual seek treatment when symptoms first occurred?
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Is the individual compliant with the treatment plan? If not, what can be done to enhance compliance?
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If attacks recur, is individual on an effective program of uric acid adjustment, which requires lifelong use of medication? Is individual capable of following a long-term medication regimen?
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Has individual developed complications such as avascular necrosis, bone deformity, kidney damage, or chronic arthritis? If so, are complications being adequately addressed in the overall treatment plan?
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Source: Medical Disability Advisor
| Francis, Mark L. "Gout." eMedicine. Eds. Anne Davidson, et al. 1 Oct. 2004. Medscape. 10 Feb. 2005 <http://emedicine.com/med/topic924.htm>.Matsen, Frederick A. "Gout." University of Washington Orthopaedics & Sports Medicine. 4 Sep. 2001. University of Washington. 29 Oct. 2004 <http://www.orthop.washington.edu/arthritis/types/gout/01>. |
Source: Medical Disability Advisor
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