Gout is an inflammatory arthritis caused by excess uric acid in the bloodstream.  The symptoms of gout arise due to uric acid crystals that are deposited in the joints and the body’s response to them.  The pain is often so intense, anything touching the joint involved, including clothing or socks, causes extreme pain.  The most common joint affected is the big toe, with patients often commenting that even their bedsheet hurts the toe.  As this is a potentially destructive joint disease, it is important to be able to recognize in a chiropractic office and differentiate from other joint disorders.  This article will discuss how a chiropractor can identify and assist in the care for gout. 

Recognizing Gout:
Gout typically has a very rapid onset.  Often patients wake up with extreme joint tenderness; the joint involved will be red and inflamed often looking like an infection.  As said before, when it is the big toe, “even the sheet hurts” is a common complaint.  Walking also hurts as the big toe is used to push off.  

If you have a red inflamed joint, please proceed to your family doctor. Your chiropractor should send you there anyways, as an inflamed joint could very well be an infection.  An infected joint can spread very quickly, a much more emergent situation.  Blood work needs to be done to check for infection and uric acid levels.  Any chiropractic manipulation at this point would be way too painful for the patient and potentially damaging if there are joint erosions already starting.  Once the inflammation has settled, and a diagnosis has been determined, the chiropractor can then determine if it is safe for any chiropractic manipulation or mobilization. 

Risk Factors:
Diet is the biggest risk factor for Gout.  Historically, Gout was only seen in wealthy middle aged men.  They had money to eat meat and drink alcohol often.  This is a disease where there haven’t been a lot of advances in terms of treatment management.  The same medications have been used to treat for decades.  Besides the risks of a diet high in meat and seafood, obesity, sedentary lifestyle, a frequent consumption of high fructose corn syrup has recently been associated with Gout.  High fructose corn syrup is a sweetener found in many processed foods.  Studies have confirmed that high fructose corn syrup increases uric acid levels in the blood.  This product is often used in foods that are labelled “low fat”, but you can find it in ketchup, all kinds of processed sauces, salad dressings, soft drinks, cereals, and the list goes very long. 

The following medications have been associated with Gout:  Thiazide diuretics (used in treating Hypertension), low dose ASA (used to prevent heart attack or stroke), Cyclosporine (immunosuppressants), Nicotinic acid (Vitamin B3, used to treat high cholesterol) and Levodopa (used in treating muscle disorders like Parkinson’s disease). 

The demographics for Gout include advanced age in men (starting 60-65) and postmenopausal women.  The biological mechanisms that have been proposed in women relate to the levels of estrogen and progesterone.  In premenopausal women, the presence of hormones allow for a more efficient renal clearance of urate.  Women maintain a “juvenile level” of urate levels for most of their young adulthood and do not reach maximum levels until after menopause.  Contrast that to men, who attain their “adult levels” around the time of puberty. 

Other comorbidities exist which increase your likelihood of developing Gout.  These include: Hypertension, cardiovascular disease, chronic renal disease, diabetes mellitus, dyslipidemia, and metabolic syndrome. 

Treatment of Gout
With an initial acute episode of Gout, your family doctor will treat with anti-inflammatories (NSAIDS: Naproxen or Indomethacin).  Keep in mind that this does not treat the underlying cause of the disease, but addresses the inflammation that is occurring.  When there are greater than 2 attacks of acute Gout in a year, then your family doctor should assess the indications for pharmacological urate-lowering therapy (Allopurinol).  Ideal serum uric acid levels should be below 360 μmol/L as studies have shown that uric acid crystals do not dissolve in joints at a concentration above this level, much like excessive sugar in an unstirred hot drink.  Chronic Gout pharmacological management is recommended when serum uric acid levels are not getting below this desired level to prevent the advanced Gout symptoms of Tophi production (uric acid filled masses or lesions), persistent arthritic destruction and kidney disease. 

From a chiropractic stand point, we can make the biggest impact by recognizing the symptoms and referring to the appropriate professional.  In addition, once an acute flare has occurred and diagnosed as gout, we can help with nutritional recommendations. 

Uric acid is produced from the metabolism of Purines, adenine and guanine.  There are all kinds of websites that list the foods to avoid for Gout.  In general, limit your consumption of animal meats and seafood, animal organs, high fructose corn syrup, alcohol (beer and hard liquor more than wine) and caffeinated beverages.  Please click on the Purine Table to see an extensive list of purine containing foods to make more informed food choices.  Please also see the info picture located after this article in the newsletter. 

Overall, Gout is a disease that can be controlled well through diet and lifestyle changes.  Chiropractors assess and treat joint issues and diseases.  Although we do not treat during an acute flare up for Gout, your chiropractor may provide you with valuable information in terms of the management of this disease and will have recommendations for a proper plan of action.