PHSI N203F Orthopaedics and Musculoskeletal Physiotherapy I Lecture 4b PDF

PHSI N203F Orthopaedics and Musculoskeletal Physiotherapy I Lecture 4b Physiotherapy management of common musculoskeletal dysfunction related to rheumatic diseases Gouty Arthritis...

PHSI N203F Orthopaedics and Musculoskeletal Physiotherapy I Lecture 4b Physiotherapy management of common musculoskeletal dysfunction related to rheumatic diseases Gouty Arthritis Dr. Chan Wing Nga Acknowledgment: Prof. Kevin SC Kwong Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Definition “An inflammatory arthritis” “A crystal deposition disease caused by deposition of monosodium urate (MSU) crystal in joints and other tissues, secondary to hyperuricemia” Hyperuricemia Elevated uric acid level in blood (Creamer & Kassimos, 2018; Fenando et al., 2022; George & Minter, 2022) Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management  https://www.freepik.com/free- photos-vectors/skeleton- Epidemiology drawing Disease of kings and King of diseases Prevalence = 1-4% Knee joint Most common inflammatory joint disease in men Peak onset in 50s; prevalence plateaus after 70 years old Talocrural and subtalar Older females on diuretics joints 2nd attack: ~60% in 1 year ~80% in 3 years 1st MTPJ Serum urate level > 9 mg/dL → 3x more likely to have flare-up in 12 months (Creamer & Kassimos, 2018; Fenando et al., 2022) Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management  Etiology Urate Over-production Under-excretion Chronic kidney disease Myeloproliferative Hypertension Hyperuricemia disorders Hyperparathyroidism Hemolysis Alcoholism MAY Lesch-Nyhan syndrome Drugs (e.g. diuretics, aspirin) Extreme exercise Lead poisoning (saturnine gout) Obesity Gout Other triggers Often take 20-30 years to Stress develop Dietary factors Drugs (Creamer & Kassimos, 2018; Fenando et al., 2022; Gaillard & Yap)  Risk factors Risk factors Modifiable or non-modifiable Older age Hypertension Male (M:F = 20:1) Hyperlipidemia Family history / genetic variants Diabetes mellitus Ethnicity Cardiovascular disease Medication altering urate balance (e.g. diuretics, low-dose aspirin) Chronic renal impairment Obesity Purine diet (e.g. red meats, organ meats, alcohol, seafood, sweetened beverages) Alcohol (Creamer & Kassimos, 2018; Fenando et al., 2022) Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Pathology Chronic Asymptomatic Acute gouty Intercritical tophaceous hyperuricaemia arthritis gout gout (Creamer & Kassimos, 2018; Fenandoet al., 2022)  Pathology Chronic Asymptomatic Acute gouty Intercritical tophaceous hyperuricaemia arthritis gout gout Majority of patients never develop gout (Creamer & Kassimos, 2018; Fenandoet al., 2022) Pathology Chronic Asymptomatic Acute gouty Intercritical tophaceous hyperuricaemia arthritis gout gout Involve: Joint periarticular structures (Creamer & Kassimos, 2018; Fenandoet al., 2022) Pathology Chronic Asymptomatic Acute gouty Intercritical tophaceous hyperuricaemia arthritis gout gout Between acute attacks For some patients: incomplete remission → persistence pain Hyperuricemia persists (Creamer & Kassimos, 2018; Fenandoet al., 2022)  (Creamer & Kassimos, 2018; Fenandoet al., 2022) Pathology Chronic Asymptomatic Acute gouty Intercritical tophaceous hyperuricaemia arthritis gout gout Gouty tophi Appear ~12 yrs after initial gouty attack Solid urate crystal collections Nodules with increased vascularity Chronic inflammation Maybe intra-articular, periarticular, or extra-articular → destructive deforming arthritis + bone destruction https://www.pcds.org.uk/clinical- May also deposit in cornea and heart valves guidance/gouty-tophi Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Diagnosis Plasma or serum urate DDx: concentrations > 6.8 mg/dL Septic arthritis Level of serum uric acid (SUA) Osteoarthritis Men: > 420 μmol/L Trauma Women: > 360 μmol/L Cellulitis **only around 5-10% of patients with SUA > 420 μmol/L are diagnosed with gout. Asymptomatic hyperuricaemia is 10 times more common than gout https://www.knee-pain-explained.com/gout-knee.html https://www.babylonhealth.com/en-us/what-we-treat/skin-conditions/cellulitis (Creamer & Kassimos, 2018; Fenando et al., 2022) Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Clinical features Rapid development of symptoms (< 24 hours) Severe pain, painful on touching, not responsive to home remedies Erythema Swelling  Temperature Maximum intensity of pain at 24 hours Monoarticular Common at night and in early morning Fever may occur (polyarticular attack) https://www.physio-pedia.com/Gout Acute phase lasts for < 10 days Intermittent painful attacks with long period of remission (Creamer & Kassimos, 2018; Fenandoet al., 2022) Gouty arthritis Definition Epidemiology Etiology Pathology Diagnosis Clinical features Management Management of gout (Hui et al., 2017) Treatment Symptoms resolved in < 10 days Acute Chronic Control pain and Patient education inflammation Lifestyle modification Weight loss Dietary advice Pharmacological Non-pharmacological management management (start in 24-hr) Rest Ice Splinting (Creamer & Kassimos, 2018) What are the roles of physiotherapist in managing gout?  RA vs OA vs Gout OA RA Gout Degenerative joint disease Systemic autoimmune Secondary to disorder hyperuricemia Non-symmetrical Symmetrical Non-symmetrical Non-inflammatory Inflammatory Inflammatory Affects weight-bearing Affects peripheral joints Monoarticular joints (mainly distal joints) Morning stiffness < 30 min Morning stiffness > 1 hour Sudden onset in few days Affecting F>M Affecting M>F Peak incidence: Peak incidence: 40-50 y.o. Peak incidence: 50 y.o. References (Gout) Creamer, P., Kassimos, D. (2018). Crystal deposition disorders. In: Blom, A., Warwick, D., & Whitehouse, M. Apley and Solomon's system of orthopaedics and trauma (10th ed.). Boca Raton, Florida: CRC Press, Taylor & Francis Group. Fenando, A., Rednam, M., Gujarathi, R., Widrich, J. (Updated 2022 May 21). Gout. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546606/ Gaillard, F., Yap, J. Gout. Retrieved on 1 September 2022 from Radiopaedia.org. https://doi.org/10.53347/rID-1395. George, C., Minter, D.A. (Updated 2022 Jul 18). Hyperuricemia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459218/ Hui, M., Carr, A., Cameron, S., Davenport, G., Doherty, M., Forrester, H., Jenkins, W., Jordan, K. M., Mallen, C. D., McDonald, T. M., Nuki, G., Pywell, A., Zhang, W., Roddy, E. (2017). British Society for Rheumatology Standards, Audit and Guidelines Working Group. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford). 56(7):e1-e20. doi: 10.1093/rheumatology/kex156. Stewart, S., Guillen, A. G., Taylor, W. J., Gaffo, A., Slark, J., Gott, M., Dalbeth, N. (2020). The experience of a gout flare: a meta-synthesis of qualitative studies. Semin Arthritis Rheum. 50(4):805-811. doi: 10.1016/j.semarthrit.2020.06.001. Patient resources (Gout) American College of Rheumatology: https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases- Conditions/Gout https://www.rheumatology.org/Portals/0/Files/Gout-Fact-Sheet.pdf Arthritis Foundation: https://www.arthritis.org/diseases/gout Centre of Health Protection, Department of Health: https://www.chp.gov.hk/files/pdf/ncd_watch_april_2019_chin.pdf