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INTRODUCION-

Gout is a common form of inflammatory arthritis that is very painful. It usually affects one joint at a time (often the big toe joint). There are times when symptoms get worse, known as flares, and times when there are no symptoms, known as remission. Repeated bouts of gout can lead to gouty arthritis, a worsening form of arthritis.

There is no cure for gout, but you can effectively treat and manage the condition with medication and self-management strategies.

Gout is a general term for a variety of conditions caused by a buildup of uric acid. This buildup usually affects your feet.

If you have gout, you’ll probably feel swelling and pain in the joints of your foot, particularly your big toe. Sudden and intense pain, or gout attacks, can make it feel like your foot is on fire.

SYMPTOM-

Gout flares start suddenly and can last days or weeks. These flares are followed by long periods of remission—weeks, months, or years—without symptoms before another flare begins. Gout usually occurs in only one joint at a time. It is often found in the big toe. Along with the big toe, joints that are commonly affected are the lesser toe joints, the ankle, and the knee.

Some people have too much uric acid in their blood, but no symptoms. This is called asymptomatic gout.

Acute gout symptoms come on quickly from the buildup of uric acid crystals in your joint and last for 3 to 10 days. You’ll have intense pain and swelling, and your joint may feel warm. Between gout attacks you won’t have any symptoms.

If you don’t treat gout, it can become chronic. Hard lumps called tophi can eventually develop in your joints and the skin and soft tissue surrounding them. These deposits can permanently damage your joints.

Prompt treatment is important to prevent gout from turning chronic.

Symptoms in the affected joint(s) may include:

• Pain, usually intense.
• Swelling.
• Redness.
• Heat.

The buildup of uric acid in your blood from the breakdown of purines causes gout.

Certain conditions, such as blood and metabolism disorders or dehydration, make your body produce too much uric acid.

A kidney or thyroid problem, or an inherited disorder, can make it harder for your body to remove excess uric acid.

You’re more likely to get gout if you:

• are a middle-aged man or postmenopausal woman
• have parents, siblings, or other family members with gout
• eat too much purine-rich food, such as red meats, organ meats, and certain fish
• drink alcohol
• take medications such as diuretics and cyclosporine
• have a condition like high blood pressure, kidney disease, thyroid disease, diabetes, or sleep apnea

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ETIOLOGY-

Gout is caused by a condition known as hyperuricemia, where there is too much uric acid in the body. The body makes uric acid when it breaks down purines, which are found in your body and the foods you eat. When there is too much uric acid in the body, uric acid crystals (monosodium urate) can build up in joints, fluids, and tissues within the body. Hyperuricemia does not always cause gout, and hyperuricemia without gout symptoms does not need to be treated.

Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood.

Your body produces uric acid when it breaks down purines — substances that are found naturally in your body.

Purines are also found in certain foods, such as steak, organ meats and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose).

Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Risk factors

You’re more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:

• Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.
• Obesity. If you’re overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
• Medical conditions. Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.
• Certain medications. The use of thiazide diuretics — commonly used to treat hypertension — and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.
• Family history of gout. If other members of your family have had gout, you’re more likely to develop the disease.
• Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women’s uric acid levels approach those of men. Men are also more likely to develop gout earlier — usually between the ages of 30 and 50 — whereas women generally develop signs and symptoms after menopause.
• Recent surgery or trauma. Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout attack.

Complications

People with gout can develop more-severe conditions, such as:

• Recurrent gout. Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
• Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren’t painful, but they can become swollen and tender during gout attacks.
• Kidney stones. Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.

Prevention

During symptom-free periods, these dietary guidelines may help protect against future gout attacks:

• Drink plenty of fluids. Stay well-hydrated, including plenty of water. Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.
• Limit or avoid alcohol. Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.
• Get your protein from low-fat dairy products. Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.
• Limit your intake of meat, fish and poultry. A small amount may be tolerable, but pay close attention to what types — and how much — seem to cause problems for you.
• Maintain a desirable body weight. Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.

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TREATMENT-

Gout can be effectively treated and managed with medical treatment and self-management strategies. Your health care provider may recommend a medical treatment plan to

• Manage the pain of a flare. Treatment for flares consists of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, steroids, and the anti-inflammatory drug colchicine.
• Prevent future flares. Making changes to your diet and lifestyle, such as losing weight, limiting alcohol, eating less purine-rich food (like red meat or organ meat), may help prevent future attacks. Changing or stopping medications associated with hyperuricemia (like diuretics) may also help.
• Prevent tophi and kidney stones from forming as a result of chronic high levels of uric acid. Tophi are hard, uric acid deposits under the skin. For people with frequent acute flares or chronic gout, doctors may recommend preventive therapy to lower uric acid levels in the blood using drugs like allopurinol, febuxostat, and pegloticase.

In addition to medical treatment, you can manage your gout with self-management strategies. Self-management is what you do day to day to manage your condition and stay healthy, like making healthy lifestyle choices. The self-management strategies described below are proven to reduce pain and disability, so you can pursue the activities important to you.

Gout foods to avoid

Certain foods are naturally high in purines, which your body breaks down into uric acid. Most people don’t have a problem with high-purine foods, but if your body has trouble releasing excess uric acid, you may want to avoid foods and drinks like these:

• red meats
• organ meats
• certain seafood
• alcohol

Sugar-sweetened beverages and foods containing the sugar fructose can also be problematic, even though they don’t contain purines.

Certain foods help reduce uric acid levels in the body.

Gout home remedies

Some gout-relief methods don’t come in a bottle from your pharmacy. Evidence from studies suggests that these natural remedies may help lower uric acid levels and prevent gout attacks:

• tart cherries
• magnesium
• ginger
• apple cider vinegar
• celery
• nettle tea
• dandelion
• milk thistle seeds

Gout surgery

Gout can typically be treated without surgery. But after many years, this condition can damage the joints, tear the tendons, and cause infections in the skin over the joints.

Hard deposits, called tophi, can build up on your joints and in other places, like your ear. These lumps may be painful and swollen, and they can permanently damage your joints.

Three surgical procedures treat tophi:

• tophi removal surgery
• joint fusion surgery
• joint replacement surgery

Which one of these surgeries your doctor recommends depends on the extent of the damage, where the tophi are located, and your personal preferences.

PHYSIOTHERAPY MANAGEMENT –

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

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