Musculo-Skeletal Disorders - Gout

by Kyle J. Norton

Musculoskeletal disorders (MSDs) is medical condition mostly caused by work related occupations and working environment, affecting patients' muscles, joints, tendons, ligaments and nerves and developing over time. A community sample of 73 females and 32 males aged 85 and over underwent a standardised examination at home. Musculoskeletal pain was reported by 57% of those interviewed. A major restriction of joint movement range was frequent in the shoulder but uncommon in other joints. A shoulder disorder was found in 27% of subjects, rheumatoid arthritis in 1% and osteoarthritis (OA) of the hand, hip, and knee in five, seven, and 18% of subjects, respectively. Disability was frequent: a walking distance of < 500 m was found in 60% and ADL dependency in 40% of the group. Factors related to one or both of these disability measures included female gender, hip and knee OA, impaired vision, cognitive impairment and neurological disease(1a). Gout I. Gout mostly effected one joint is defined as a acute and recurrent condition of arthritis as a result of uric acid builds up in blood cause of joint inflammation. II. Symptoms In the study carry out a cross-sectional survey on prevalence of musculoskeletal symptoms, rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout, Dr. Dai SM, and the research team at the Second Military Medical University, in the interviewe a total of 6584 adults (3394 women, 3190 men) with the response rate of 86.6%. showed that symptoms occurred more frequently in the following sites: knee 7.0% (95% CI 6.47.6%), lower back 5.6% (95% CI 5.0-6.2%), shoulder 4.7% (95% CI 4.25.2%), and neck 2.4% (95% CI 2.0-2.8%). Women complained of rheumatic symptoms more frequently than men. The standardized rates of RA, AS, gout, symptomatic knee osteoarthritis, and soft tissue rheumatism were 0.28% (95% CI 0.15-0.41%), 0.11% (95% CI 0.03-0.19%), 0.22% (95% CI 0.11-0.33%), 4.1% (95% CI 3.6-4.6%), and 3.4% (95% CI 3.0-3.8%), respectively(1a). In fact, symptoms are quite noticeable, you may feel well when you go to bed but wake up during the night with intense pain in one or few joints and sometime with fever. The symptoms may go away in a few days, but can

return from time to time. Chronic gout can cause lumps below the skin around joints. III. Causes and risk factors A. Causes The causes of gout is as the result of high levels of uric acid in the body that can lead to forming of crystals causes of inflammation due to your body can not get rid of uric acid or have made too much uric acid. B. Risk factors 1. If you body can not get rid uric acid quickly, intake foods with high levels of purine such as Alcohol, Beverages, Beer, Anchovies, Smelt, Fish, Eggs, Herring, Mackerel, Sardine, Sweetbread, Liver, Kidney, etc., is at increased risk of gout. 2. Dr. Singh JA and scientists at the Birmingham VA Medical Centre, indicated that of the 751 titles and abstracts, 53 studies met the criteria and were included in the review. Several risk factors were studied. Alcohol consumption increased the risk of incident gout, especially beer and hard liquor. Several dietary factors increased the risk of incident gout, including meat intake, seafood intake, sugar sweetened soft drinks, and consumption of foods high in fructose. Diary intake, folate intake, and coffee consumption were each associated with a lower risk of incident gout and in some cases a lower rate of gout flares. Thiazide and loop diuretics were associated with higher risk of incident gout and higher rate of gout flares. Hypertension, renal insufficiency, hypertriglyceridemia, hypercholesterolemia, hyperuricemia, diabetes, obesity, and early menopause were each associated with a higher risk of incident gout and/or gout flares(2). Others suggested that combined with their activities as urate transporters and their strong associations with serum uric acid concentrations, 4. Genetics GLUT9 and ABCG2 appeared to be important modulators of uric acid levels and likely of the risk of gout. Together with a growing list of environmental risk factors, these genetic data add considerably to our understanding of the pathogenesis of hyperuricemia and gout(3). 5. Medication Thiazide and loop diuretics users are at increased risk of gout(4) 6. Obesity, weight change, hypertension Higher adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective. Hypertension and diuretic use are also important independent risk factors for gout(5). Others showed that Gout is also drug-related and associated with increased obesity, hypertension,

insulin resistance and metabolic syndrome(6). In other study, researchers found that women often have endocrine pathology (artificial menopause, dysmenorrhea, euthyroid goiter). In women gout runs a more severe course manifesting in early chronization, polyarticularity, lingering arthritis, rapid formation of tophuses. Both groups demonstrated marked polymorbidity with accumulation of the diseases related to atherosclerosis. Distinct group differences by content of uric acid seem to arise from early onset of chronic renal failure in women. 7. Chronic kidney disease Patient with Chronic kidney disease are at higher risk of gout as a result of Serum uric acid control in gout was poor among patients without CKD and even worse among those with CKD(7). 8. Menopause, postmenopausal hormone use In a study of 16 years of follow-up (1 240 231 person-years), 1703 incident gout cases were recorded. ,the incidence rate of gout increased from 0.6 per 1000 person-years in women <45 years of age to 2.5 in women > or =75 years of age (p for trend <0.001). Compared with premenopausal women, postmenopausal women had a higher risk of incident gout (multivariateadjusted relative risk (RR)=1.26; 95% confidence interval (CI) 1.03 to 1.55). Among women with a natural menopause, women with age at menopause <45 years had a RR of 1.62 (95% CI 1.12 to 2.33) of gout compared with women with age at menopause 50-54 years. Postmenopausal hormone users had a reduced risk of gout (RR=0.82; 95% CI 0.70 to 0.96). Menopause increases the risk of gout, whereas postmenopausal hormone therapy modestly reduces gout risk(8). 9. Etc. IV. Diagnosis and test After taking family history and physical exam together with the examination of joint infected, your doctor may order the following test 1. Blood Test for Uric Acid Levels The aim of the test is to measure the levels of uric acid. People who have a high levels of uric acid are at increased risk of gout. 2. Urine test The aim of the urine test is to examine the levels of uric acid produced from the natural breakdown of your body's cells and from the foods you eat by measuring the amount of uric acid in a sample of urine collected over 24 hours..

3. Synovial fluid analysis The aim of the test is to examine the joint (synovial) fluid for the the presence of monosodium urate (MSU) crystals for confirmation of gout. 4. X ray Although X ray is considered helpless in the early stage of gout, in the progressing stage, tophi can be see. 5. Other tests such Computed tomography(CT), magnetic resonance imaging(MRI) and ultrasonography(US) In the study to determine the usefulness of computed tomography (CT), magnetic resonance imaging (MRI), and Doppler ultrasonography (US) in providing specific images of gouty tophi, found that MR and colour Doppler US images showed the tophi as masses surrounded by a hypervascular area, which cannot be considered as specific for gout. But on CT images, masses of about 160 HU density were clearly seen, which correspond to MSU crystal deposits(8a). 6. Etc. V. Prevention A. The Do's and Do not's list 1. Coffee If you are drinking coffee, researchers found that long-term moderate coffee consumption is associated with a lower risk of incident gout in women(9). 2. Maintaining adequate fluid intake Dehydrate is associated with the increased risk of gout. Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management(10). 3. Weight reduction Obesity cause cause pressure to the joint. Obesity is not only a risk factor for incident gout but is associated with an earlier age at gout onset(11). 4. Dietary changes a. Reduce alcohol Alcohol intake is strongly associated with an increased risk of gout. This risk varies substantially according to type of alcoholic beverage: beer confers a larger risk than spirits, whereas moderate wine drinking does not

increase the risk(12). b. Reduce intake of foods with high levels of purine, such as sardines, herring, kidney and sweetbreads, shrimp, etc. c. Diet with foods to prevent gout Dairy products, vegetables, nuts, legumes, fruits (less sugary ones), and whole grains are healthy choices for the comorbidities of gout and may also help prevent gout by reducing insulin resistance. Coffee and vitamin C supplementation could be considered as preventive measures as these can lower urate levels, as well as the risk of gout and some of its comorbidities. Diet with foods such as cherries and strawberries to prevent goutDairy products, vegetables, nuts, legumes, fruits (less sugary ones), and whole grains are healthy choices for the comorbidities of gout and may also help prevent gout by reducing insulin resistance. Coffee and vitamin C supplementation could be considered as preventive measures as these can lower urate levels, as well as the risk of gout and some of its comorbidities(13). Other researchers suggested that some in vivo evidence of the impact of strawberry intake on the folate status in humans have already been reported, but a new increasing interest on this field is strongly hoped. Furthermore, the hypouricaemic effects previously ascribed to cherry consumption need to be evaluated in respect to strawberry intake. At the moment, inconsistent results come from the few investigations designed at this proposal. In our studies, a great interindividual variability was observed on plasma urate levels in response to strawberry intake, suggesting a putative effect(14). 5. Reduce intake of medications which can cause gout by reviewing them with your doctor, as certain medicine such as Thiazide and loop diuretics. 6. Exercise "Exercises to relieve gout should be done steady and cautiously as to avoid further irritation to the joints. The best exercises for gout are range of motion types: strength training, stretching and building endurance. Yoga is an exercise that incorporates all four; however, there are other exercises that can be done individually also" According to the article of How to Exercise If You Have Gout(14a) 7. Etc.

B. Phytochemicals to prevent Gout 1. Quercetin and Rutin Dr. Zhu JX and research team at the School of Life Sciences, Nanjing University found that the effects of quercetin and rutin on serum urate levels in hyperuricemic mice induced by oxonate and the inhibition of enzyme activities in mouse liver are discussed in relation to their absorption and metabolism, and their potential application to treat gout and hyperuricemia(15). 2. Morin Morin (3,5,7,2',4'-pentahydroxyflavone) a phytochemical found in the twigs of Morus alba L. documented in traditional Chinese medicinal literature to treat conditions akin to gout, was demonstrated to exert potent inhibitory action on urate uptake in rat renal brush-border membrane vesicles, indicating that this compound acts on the kidney to inhibit urate reabsorption(16). 3. Other phytichemicals In the study of 15 flavonoids (quercetin, morin, myricetin, kaempferol, icariin, apigenin, luteolin, baicalin, silibinin, naringenin, formonoetin, genistein, puerarin, daidzin and naringin dihydrochalcone) selected to investigate for their hypouricemic action in mice, found that Oral administration of quercetin, morin, myricetin, kaempferol, apigenin and puerarin at 50 and 100 mg/kg for 3 d was able to elicit hypouricemic actions in hyperuricemic mice induced by potassium oxonate. Luteolin, formonoetin and naringenin showed the significant effects only at 100 mg/kg. Quercetin, puerarin, myricetin, morin and kaempferol significantly reduced liver uric acid level in hyperuricemic animals. In addition, quercetin, morin, myricetin, kaempferol and puerarin exhibited significant inhibition on the liver xanthine oxidase (XOD) activities(17). 4. Etc. VI. Treatments A. In conventional medicine perspective A.1. Acetaminophen a. Acetaminophen such as Tylenol can help to relive the pain of Gout. b. Side effects if overdose are not limit to b.1. Nausea and vomiting

b.2. Appetite loss b.3. Sweating b.4. Diarrhea b.5. Irritability b.6. Abdominal pain b.7. Etc. A.2. In the study of Gout--what are the treatment options? indicated that The options available for the treatment of acute gout (18)are 1. NSAIDs a. NSAIDs are commonly prescribed to control gout attacks in patients with hyperuricaemia. b. Side effects are not limit to Dr. Bjarnason I, and the research team at King's College School of Medicine and Dentistry, in the study of Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans, showed that Ingested NSAIDs may cause a nonspecific colitis (in particular, fenemates), and many patients with collagenous colitis are taking NSAIDs. Large intestinal ulcers, bleeding, and perforation are occasionally due to NSAIDs. NSAIDs may cause relapse of classic inflammatory bowel disease and contribute to serious complications of diverticular disease (fistula and perforation). NSAIDs may occasionally cause small intestinal perforation, ulcers, and strictures requiring surgery. NSAIDs, however, frequently cause small intestinal inflammation, and the associated complications of blood loss and protein loss may lead to difficult management problems. The pathogenesis of NSAID enteropathy is a multistage process involving specific biochemical and subcellular organelle damage followed by a relatively nonspecific tissue reaction. The various possible treatments of NSAID-induced enteropathy (sulphasalazine, misoprostol, metronidazole) have yet to undergo rigorous trials(19). 2. Colchicine a. Colchicine, used for a long period in gout, was approved for the first time in 2009 by the FDA for the prophylaxis and the treatment of acute attack, on the basis of a pivotal trial that showed the efficacy in the very short term that is 24 h of a well-tolerated, low-dose regimen of Colcrys (colchicine, URL Pharma, Philadelphia, USA) to reduce pain in patients with acute gout - when given early(20). b. Side effects are not limit to 1. Diarrhea

2. Dizziness 3. Flushing 4. Hair loss 5. Headache 6. Loss of appetite 7. Nausea; sore gums 8. Stomach pain 9. Vomiting 10. Etc. 3. Corticosteroids a. researchers suggested that Systemic corticosteroids could be used in severe polyarticular flares. Anti-IL1 should provide a therapeutic alternative for severe cortico dependant gout with tophus. To prevent acute flares and reduce tophus volume, uric acid serum level should be reduced and maintained below 60mg/L (360mol/L). b. Side effects are not limit to b.1. Stomach irritation b.2. Rapid heartbeat b.3. Nausea b.4. Insomnia b.5. A metallic taste in the mouth b.6. Etc. 4. Adrenocorticotropic hormone (ACTH) and a. In the study of Effects of adrenocorticotropic hormone (ACTH) in gout by Alexander B. Gutman, M.D.1, T.F. Y, M.D indicated that ACTH effected a very rapid and satisfactory response in the local and systemic manifestations of acute gout in seven of eleven cases treated, including one patient refractory to colchicine. ACTH therefore appears to be a useful agent in the therapy of acute gout. In many of these patients, however, ACTH was not convincingly superior to colchicine, and in four instances colchicine terminated attacks responding unsatisfactorily to ACTH. Unlike colchicine, ACTH is not suitable for prophylactic use in the prevention of acute gouty attacks(20). b. Side effects are not limit to In the study of 162 children with infantile spasms were treated with ACTH at the Children's Hospital, Helsinki, and at the Aurora Hospital, Helsinki, during 1960--76. In a large proportion (37%) of the children the treatment caused pronounced side effects, and the mortality was 4.9%. The most common complications were infections: septic infections, pneumonias, and urinary and gastrointestinal infections. Other side effects were

arterial hypertension (11), osteoporosis (2), hypokalaemic alkalosis (2), and other marked electrolyte disturbances (10). In children necropsy showed fresh intracerebral haemorrhages. Four children developed oliguria and hyperkalaemia during and after withdrawal of ACTH. One of them had tubular necrosis confirmed by renal biopsy. Infections were significantly more common with large doses (120 units) of ACTH than with small ones (40 units). It is concluded that side effects, even severe ones, are more common during treatment than had been assumed(21). 5. Intra-articular corticosteroids a. Intraarticular steroid injections are injected directly into an affected joint to improve joint function. b. Side effects are not limit to b.1. Infection b.2. Facial flushing b.3. Local skin atrophy and depigmentation b.4. Crystalline synovitis b.5. Allergic reaction b.6. Uterine haemorrhage b.7. Etc. The most important determinant of therapeutic success is not which antiinflammatory agent is chosen, but rather how soon therapy is initiated and that the dose be appropriate. b. Side effects are not limit to b.1. Constipation b.2. Diarrhea b.3. Dizziness b.4. Drowsiness b.5. Headache b.6. Heartburn b.7. Nausea b.8. Stomach upset b.9. Etc. 7. Etc. B. In herbal medicine perspective 1. Artichoke In the study to investigate the efficacy of Artichoke (Cynara scolymus L.) leaveshistorically used for the treatment of hyperuricemia and gout, showed that ALE inhibited XO with only minimal inhibitory action (< 5 %) at 100 microg/mL. However, when selected compounds were tested, the caffeic

acid derivatives revealed a weak XO inhibitory effect with IC (50) > 100 microM. From the tested flavones the aglycone luteolin potently inhibited XO with an IC (50) value of 1.49 microM. Luteolin 7-O-glucoside and luteolin 7-O-glucuronide showed lower XO inhibition activities with IC (50) values of 19.90 microM and 20.24 microM, respectively. However, oral administration of an aqueous ALE, luteolin, and luteolin 7-O-glucoside did not produce any observable hypouricemic effects after acute oral treatment in potassium oxonate-treated rats. After intraperitoneal injection of luteolin a decrease in uric acid levels was detected suggesting that the hypouricemic effects of luteolin are due to its original form rather than its metabolites produced by the gut flora. In conclusion, an aqueous ALE, caffeic acid derivatives and flavones exerted XO inhibitory effects in vitro but a hypouricemic activity could not be confirmed after oral administration(22). 2. Green teas Researchers suggested that although no direct molecular target has been so far elucidated for Epigallo catechin-O-gallate (EGCG), the multipotentialities of this molecule, along with its broad bioavailability, render it very attractive as a putative curative drug for various diseases such as dermatosis, gout, atherosclerosis and cancer, as Green tea anti-oxidant properties could explain its antagonistic action in some inflammatory processes(23). 3. Alfalfa In the article by By jeffwend, the author wrote that Alfalfa can help to increase uric acid levels in the urine which can help reduce the amount of uric acid available to crystallize.... And the spice turmeric and the enzyme bromelain work well together to reduce inflammation(24). 4. Devil's claw Harpagoside, a Glycoside, the chemical, principle extracted from the Devil's Claw root, contributes the natural anti-inflammatory properties and used as a Gout remedy and other painful disorders of the Musculoskeletal system(25). 5. Purple Sweet Potato In the study to investigate the hypouricemic effects of anthocyanin extracts from purple sweet potato (APSP), and allopurinol, on serum uric acid levels in hyperuricemic mice, was found that administration of a single oral dose of 100mg/kg APSP to such animals reduced the serum uric acid

concentration to 4.100.04mg/dL, compared with a concentration of 10.25 0.63mg/dL in the hyperuricemic control group(26). 6. Etc. C. In Traditional Chinese medicine perspective According to TCM asssistant in the article of "Chinese herbal formula(s) can treat or relief Gout"(27), in Chinese medicine, gout is a condition of a joint painful wind syndrome caused by 1. Damp-Heat 1.1. Painful obstruction due to the containment of Damp-Heat in the channels of that can lead to acute articular rheumatism, acute attack of gout, arthritis, hot joints, joint pain, tremors, dark urine, etc. 1.2. Chinese Herbal Formula Xuan Bi Tang used to clear and damp-Heat, unblock the Channels, eliminate painful obstruction, etc. Ingredients include a. Guang Fang Ji (Radix Aristolochiae Fangchi, Aristolochia Root, Stephania) - 15g. -expels damp heat in upper jiao, expels superficial swellings, induces urination b. Xing Ren (Semen Pruni Armeniacae, Apricot Seed) - 15g. -regulates lung Qi and water metabolism c. Yi Yi Ren (Semen Coicis Lachryma Jobi) - 15g. -tonify spleen, clear dampness, relieve painful obstructions d. Can Sha (Excrementum Bombycis Mori, Silkworm Feces) - 9g. -tonify spleen, clear dampness, relieve painful obstructions e. Ban Xia (Rhizoma Pinelliae Tematae, Pinellia Rhizome) - 9g. -dries dampness, transforms tubidity f. Lian Qiao (Fructus Forsythiae Suspensae, Forsythia Fruit) - 9g. -clears superficial heat g. Zhi Zi (Fructus Gardeniae Jasminoidis, Cape Jasmine Fruit, Gardenia) 9g. -clear heat, drains dampness, induces urination h. Hua Shi (Talcum, Talcum) - 15g. -clear heat, drains dampness, induces urination i. Chi Xiao Dou (Semen Phaseoli Calcarati) - 9g. -clears heat, drains dampness, induces urination(28) 2. Recurrent Wind-Cold-Damp 2.1. Recurrent Wind-Cold-Damp painful obstruction in which localized constraint generates Heat of that can lead to acute attack of gout, arthritis, difficulty in movement, joint pain, edema of lower extremities, painful lower limbs, rheumatism;, swelling of joints, etc. 2.2. Chinese herbal formula Gui Zhi Shao Yao Zhi Mu Tang used to disperses Damp and Wind, unblocks the Channels. moves Yang, etc.

a. Gui Zhi (Ramulus Cinnamomi Cassiae, Cinnamon, Cassia Twig) - 12g. -warms and unblocks channels b. Ma Huang (Herba Ephedrae, Ephedra Stem, ma-huang) - 6g. -unblocks channels, relieves superficial swellings c. Fu Zi (Radix lateralis Aconiti Carmichaeli, Szechuan Aconite Root, Aconite) - 6g. -warms channels, relieves pain d. Zhi Mu (Rhizoma Anemarrhenae Asphodeloidis, Anemarrhena Rhizome) - 12g. -clear heat from the joints, nourish yin e. Shaoyao (Radix Paeoniae , Peony Root) - 9g. -clear heat, nourish yin f. Bai Zhu (Rhizoma Atractyloids Macrocephaelae, Atractylodes White Rhizome) - 15g. -harmonizes ying and wei Qi levels (Bai Shao) g. Fang Feng (Radix ledebouriellae, Ledebouriella Root, Siler) - 12g. -expels wind and dampness h. Sheng Jiang (Rhizoma Zingiberis officinalis Recens, Fresh Ginger Rhizome) - 15g. -promotes Qi circulation i. Gan Cao (Radix Glycyrrhizae uralensis, Licorice Root) - 6g. -harmonizes other herbs within formula, regulates middle jiao(29). 3. Wind-Damp, Phlegm and Blood stasis 3.1. Wind-Damp, Phlegm and Blood stasis lead to acute attack of gout. arthritis, difficulty in movement, joint pain, edema of lower extremities, swelling of joints;, chills, etc. 3.2. Chinese herbal formula Shu Feng Huo Xue Tang used to disperses Damp and Wind, eliminates Blood stasis a. Gui Zhi (Cinnamon twig, cassia twig) 2.5g b. Qiang Huo (Notopterygium root, chiang-huo) 2.5g c. Bai Zhi (Angelica root) 2.5g d. Huang Bai (amur cork tree bark, phellodendron bark) 2.5g e. Wei Ling Xian (Chinese clematis root, clematis) 2.5g f. Cang Zhu (Atractylodes rhizome) 2.5g g. Chuan Xiong (Sichuan lovage root, cnidium, Chuanxiong root) 2.5g h. Hong Hua (Safflower flower, Carthamus) 1g i. Gan Jiang (Dried ginger rhizome) 1g j. Dang Gui (Chinese angelica root) 2.5g k. Dan Nan Xing (P Arisaematis cum Fel Bovis) 2.5g l. Han Fang Ji (Stephania root) 2.5g(30) Natural Remedy For Arthritis, Gout, And Rheumatism Discover An Amazing, All-natural System That Literally Stops Arthritis, Gout, And Rheumatism In As Little As 7 Days.

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