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Physio Matters

Management of Gout

Gout is a painful inflammatory condition caused by an increase in uric acid levels that result in the deposit of monosodium urate crystals in specific joints of the body. Uric acid is formed when purines (molecules containing nitrogen) are metabolized (broken down), which then combine with sodium in the body to form urate crystals. When urate levels in the blood reach 6.8 mg/dL there is a greater likelihood of the crystals forming and depositing in specific joints, causing pain, swelling, inflammation, and redness. If left untreated over time, these crystals can form larger lumps called tophi, which can lead to damage of the joint. Symptoms of gout include rapid onset of pain, usually during the night, with pain reaching its maximum within 6 to 12 hours of onset. Typically gout affects the big toe at the metatarsophalangeal joint, however, joints of the foot, ankle, knee, hand, and wrist can also be affected. Initial episodes of gout can be separated by years, but if left untreated episodes may become more frequent.

Gout typically occurs in men more than women, with the average onset being between the ages of 40 and 60. Medical conditions such as obesity, high blood pressure, diabetes, and reduced kidney function are associated with the onset of gout. In addition, medications such as diuretics, anti-hypertensives, and lipid lowering drugs can affect kidney function, and therefore alter the mechanism in which uric acid is broken down.

Diet can also play a role in the onset of gout. Research has shown that foods rich in purines are associated with increases in uric acid levels in the blood. Examples of purine-rich foods include: beef, pork, lamb, veal, organ meats (i.e. liver, heart), tuna, halibut, herring, sardines, shrimp, lobster, scallops, beer, wine, asparagus, cauliflower, beans, lentils, and spinach. Interestingly, consumption of cherries has been linked to lower uric acid levels.

The diagnostic gold standard for gout is joint aspiration, where a needle is inserted into the affected joint to draw out synovial fluid. The fluid is then analyzed for the presence of urate crystals. In addition, blood tests can also be performed to determine the levels of uric acid in the blood, however, elevated levels of uric acid can exist without the presence of any symptoms. Diagnostic imaging, such as CT, MRI, and ultrasound can also be used to determine the if tophi are present in chronic cases of gout.

Your doctor may prescribe certain medications that can help to reduce uric acid levels and inflammation. Certain NSAIDs (nonsteroidal anti-inflammatory drugs) are often prescribed at the onset of the symptoms, however, other medications that also help to reduce uric acid levels and inflammation may also be prescribed. Please consult with your physician to determine which medication(s) would be most effective for your condition. In terms of non-pharmacological treatment, rest, ice, and elevation are often helpful in reducing your symptoms. Your physiotherapist may also use modalities such as ultrasound or laser in the acute phase. Range of motion, strengthening, and/or stretching exercises of the affected joint can be performed between flare ups to maintain function. If your ability to walk is compromised due to pain, your physiotherapist may also recommend a gait aid, such as a cane, to prevent you from developing poor gait patterns. Please consult with your doctor and physiotherapist to determine the best treatment plan for you.



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Muscle contusion injuries

With fall approaching, contact sports such as hockey are well underway in Kelowna. Increased sports participation also coincides with an increase in injuries, most often musculoskeletal in nature. The most common cause of soft tissue injuries in contact sports are muscle contusions and strains. A contusion is the result of a direct, blunt force, blow to an area of the body (typically a limb) that can cause damage to muscle fibers. In hockey, these types of blows may be due to contact with another player (usually knee-on-knee collisions), or slashes with a hockey stick. Symptoms of a contusion can include localized pain at the site of the blow, swelling, pain with movement, limited range of motion, and sometimes a palpable mass.

A contusion involves a partial rupture of the muscle(s), leading to the rupture of the capillaries (blood vessels), which then leads to increased bleeding. A hematoma (a collection of blood outside of the blood vessels) can then develop, as well as swelling and inflammation. Despite the damage to the tissue, the affected muscle is still able to function to some degree. The healing process involves the formation of scar tissue and the regeneration of muscle tissue.

There have been numerous studies published over the course of several years that have investigated the best treatment approaches for contusions. Immobilization (or rest) of the affected muscle has been of interest to researchers for years. As it turns out, recent research suggests that the length of time a muscle is immobilized is a key factor in the healing process. Several animal and human studies have now indicated that a short period (24-48 hours) of immobilization immediately following a contusion injury allows the scar tissue connecting the muscle fibers to gain enough strength to withstand future muscle contractions in order to prevent re-rupture. Forms of immobilization may include taping, bracing, or the use of crutches for lower limb injuries. Furthermore, researchers emphasized that long-term immobilization should be avoided in order to promote return to motion and activity.

After the short period of immobilization, gradual movement of the injured area should be started within pain tolerance. Several studies suggest that this early mobilization following a short period of rest plays a great role in helping the muscle fibers to regenerate.

In addition, most people are familiar with the "RICE" principle, which stands for Rest, Ice, Compression, and Elevation. As you may have guessed, the immobilization research above can be summarized by the concept of "rest". Ice, compression, and elevation are also methods that help to limit the bleeding at the injury site. Research suggests that the application of ice causes short term vasoconstriction and decreased blood flow, but does not have any long term vascular effects. Therefore, applying ice immediately following a contusion injury has the greatest therapeutic effects. Compression of the area and elevation can help to decrease subsequent swelling to the injured muscle tissue.

If you have sustained a contusion or muscle injury please consult a health care practitioner to determine the best course of treatment for your condition. The above information summarizes some of the current research on muscle contusions, however, healing time and specific treatment protocols will vary by patient and severity of the injury.



Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) accounts for 32% of all causes of vertigo (dizziness). It can occur in adults of all ages, but often affects individuals over the age of 60, and is more common in women than in men.

Symptoms of vertigo including feeling that your surroundings are moving or spinning, as well as nausea, vomiting, or motion sickness. Symptoms typically occur when there is a change to the position or orientation of the head, especially when bending forward, looking up, lying down, or rolling over in bed. BPPV also affects balance and the person may become unsteady on their feet. In addition, abnormal eye movements (nystagmus) usually accompany the symptoms of BPPV. These eye movements typically beat rhythmically in a vertical or horizontal direction.

In approximately 35% of cases BPPV occurs without a known cause, but may also be associated with head trauma (15%), and inner ear infections (15%). BPPV has also been associated with hypertension, hyperlipidemia, migraines, and stroke.

The physiological mechanism of BPPV involves the vestibular labyrinth of the ear, which contain 3 looped structures called the semicircular canals. These canals are responsible for monitoring the rotation of the head. When calcium carbonate crystals (otoconia) become dislodged from one of the inner ear organs (utricle) they can migrate into the semicircular canals. When the head changes position, so do the crystals in the canals, which causes an unwanted flow of fluid that continues even after the head has stopped moving. This causes the body to falsely interpret that the surroundings are spinning. The direction of the nystagmus (vertical vs. horizontal) can help clinicians determine which semicircular canals are affected.

It is estimated that 50% of BPPV cases resolve spontaneously. The average duration of BPPV is 2 weeks and recurrent episodes occur in 40% of patients. Treatment of BPPV may involve specific physiotherapy maneuvers and an exercise program designed to reposition the crystals out of the semicircular canals. It is then thought that the crystals are reabsorbed by the body. The results of these maneuvers can vary, with some patients experiencing immediate relief, while others may require follow up maneuvering.

If you are experiencing vertigo or dizziness please consult with your primary care provider to determine a diagnosis for your condition. There are several other medical conditions that may cause dizziness or vertigo so it is important to seek medical attention as soon as possible. If you are diagnosed with BPPV your physiotherapist can help guide you through a series of maneuvers that may help to ease your symptoms.





Carpal tunnel syndrome

Carpal tunnel syndrome is a condition in which the median nerve becomes irritated or compressed in the carpal tunnel of the wrist.  The median nerve supplies the thumb, index finger, middle finger, and radial half of the ring finger (side closest to the thumb).  The carpal tunnel houses 9 flexor tendons and the median nerve at the base of the palm.  Carpal (wrist) bones surround the tunnel forming an arch.  The median nerve can be compressed by decreasing the size of the tunnel or increasing the size of the tendons (swelling within the tunnel).  Flexing the wrist to 90 degrees will also decrease the size of the tunnel. 

Symptoms such as pain and altered sensation (numbness, tingling) occur in the thumb, index, middle, and radial half of the ring finger, and often result in weakness in the thenar muscles (base of the thumb).  Numbness often occurs at night as it is thought that wrists may become flexed during sleep.  Loss of grip strength and generalized pain of the wrist and hand are also characteristic of this condition. 

Carpal tunnel syndrome is often idiopathic (due to an unknown cause).  However, there are some medical conditions that can lead to its onset such as: Obesity, hypothyroidism, arthritis, previous fractures of the wrist, diabetes, and pregnancy.  In addition, work related risk factors, such as excessive force, lack of ergonomic positioning, vibrational forces, and repetitive movements have been shown to be associated with the onset of this condition. 

The diagnosis of carpal tunnel involves a combination of the patient's history and description of symptoms, clinical findings, and electrodiagnostic testing.  Patients often report altered sensation in the median nerve distribution, symptoms that occur while sleeping, and weakness in the thumb muscles.  Clinically, tests such as the Phalen's maneuver and Tinel's sign can be performed in a physical assessment by a health care provider.  Phalen's maneuver involves flexing the wrist for at least 60 seconds.  A positive test is indicated when numbness and/or pain is felt in the median nerve distribution within 60 seconds.  Tinel's sign is performed by lightly tapping over the carpal tunnel.  A positive result is indicated if the tapping causes a tingling sensation in the median nerve distribution.  Electrodiagnostic testing may include nerve conduction tests that can determine median nerve abnormalities. 

Prevention of carpal tunnel syndrome involves avoiding repetitive movements, adopting more ergonomic positions and/or the use of ergonomic equipment.  Treatment may include bracing/splinting of the wrist, physiotherapy, or surgery.  Physiotherapy treatments may include ultrasound, exercise and stretching prescription, and/or manual mobilization by your physiotherapist.  Please check with your primary health care provider to determine a diagnosis for your wrist pain and the most appropriate treatment plan for your condition. 



Read more Physio Matters articles




About the Author

Kristi Scott, B.Sc., M.Sc.P.T., CAFCI

Kristi is a Registered Physiotherapist. She joined her mother, Shirley Andrusiak, at Guisachan Physiotherapy after graduating from the Masters of Science in Physical Therapy Program at the University of Alberta in 2010. She also holds an Undergraduate Bachelor of Science Degree from the University of Victoria. Since graduating Kristi has completed numerous continuing education courses including manual therapy, vertigo, sport first responder, and golf related rehabilitation.  She has also completed her training with the Acupuncture Foundation of Canada Institute, and is certified to perform acupuncture, holding a designation of CAFCI.

Kristi brings an energetic, exercise based approach to her practice. She focuses on client centered care, education, exercise prescription, and manual therapy techniques. 

You can contact Kristi by email at [email protected]

 

 




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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.


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