Foot Pain, Impairment and Disability in Patients with Acute Gout

126 Pages·2011·2.34 MB·English

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Foot Pain, Impairment and Disability in Patients with Acute Gout; a
Prospective Observational Study

Michael John Frecklington

Thesis

Submitted to AUT University in
fulfillment of the requirements for the degree of
Master of Philosophy

2011

School of Podiatry

Primary Supervisor: Prof. Keith Rome
Secondary Supervisors: Prof. Peter McNair, Dr Nicola Dalbeth
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Table of Contents:

List of tables 6
List of figures 7
Attestation of authorship 8
Ethical Approval 9
Acknowledgements 11
Abstract 13
Chapter 1: Introduction 14
1.1 Statement of problem 14
1.2 Aim of the study 16
1.3 Hypotheses 17
1.4 Significance of study 17
Chapter 2: Literature review 18
2.1 Introduction 18
2.2 Pathogenesis 18
2.3 Asymptomatic hyperuricaemia 18
2.4 Risk factors 19
2.5 Acute gout 22
2.6 Pathophysiology of acute gout 24
2.7 Clinical features of acute gout flares 24
2.7.1 Joint tenderness and joint swelling 25
2.7.2 Patient global assessment 26
2.7.3 Acute-phase marker 27
2.7.4 Serum urate 27
2.8 Intermittent gout 27
2.9 Chronic gout 28
2.10 Summary 29
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Chapter 3: Literature review of gout within the foot 30
3.1 Introduction 30
3.2 Methodology 30
3.3 Epidemiology of gout in the foot 32
3.4 Co-morbidities associated with gout in the foot 33
3.5 Pathological changes occurring at the foot in gout 34
3.6 Foot pain, impairment, function and disability 38
3.6.1 Foot pain 38
3.6.2 Foot impairment 40
3.6.3 Foot function 42
3.6.4 Foot disability 44
3.7 Summary 45
Chapter 4: Methodology 46
4.1 Study design 46
4.2 Participants 46
4.3 Procedure 46
4.4 Primary outcome measures 48
4.5 Flare characteristics 48
4.5.1 Joint tenderness and joint swelling 48
4.5.2 Patient global assessment 48
4.5.3 Acute-phase marker 49
4.5.4 Serum urate 49
4.6 Foot pain 49
4.7 Foot impairment 50
4.8 Foot function 51
4.9 Foot disability 52
4.10 Data analysis 52
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Chapter 5: Results 55
5.1 Introduction 55
5.2 Clinical characteristics 56
5.3 Gout history 56
5.4 Clinical features of acute flares 58
5.5 Foot pain 63
5.6 Foot impairment 64
5.7 Foot function 65
5.8 Foot disability 67
5.9 Summary 69
Chapter 6: Discussion 70
6.1 Introduction 70
6.2 Clinical characteristics 70
6.3 Gout history 71
6.4 Prevalence of acute gout in the foot 72
6.5 Flare characteristics 74
6.5.1 Joint tenderness and joint swelling 74
6.5.2 Patient global assessment 75
6.5.3 Acute phase marker 75
6.5.4 Serum urate 76
6.6 Foot pain 76
6.7 Foot impairment 78
6.8 Foot function 79
6.9 Foot disability 80
6.10 Limitations 81
6.11 Future directions 82
6.12 Conclusion 83
Declaration of conflict of interest 85
Chapter 7: References 86
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Appendices 107
Appendix 1: American College of Rheumatology Criteria for the
Classification of Acute Arthritis for Primary Gout 107
Appendix 2: Patient Information Sheet 108
Appendix 3: Informed Consent Form 111
Appendix 4: ARA 66/68 Joint Count for Swollen and Tender Joints 113
Appendix 5: Pain 100mm Visual Analogue Scale 115
Appendix 6: Modified Foot Function Index 116
Appendix 7: Structural Indices for Forefoot and Hindfoot Deformities 117
Appendix 8: Foot Posture Index 118
Appendix 9: Leeds Foot Impact Scale 119
Appendix 10: Health Assessment Questionnaire II 123
Appendix 11: Lower Limb Tasks Questionnaire: Activities of Daily Living 124
Appendix 12: Lower Limb Tasks Questionnaire: Recreational Activities 125
Appendix 13: Bonferroni Correction with Holm and
Hochberg Adjustments 126
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List of tables

Table 3.1: Typical values for pain during acute gout flares 39
Table 5.1: Descriptive information for study sample at baseline 56
Table 5.2: Gout history 57
Table 5.3: Clinical features of gout flares 59
Table 5.4: Descriptive information of measures of pain, impairment,
function and disability 60
Table 6.1: Prevalence of 1st MPJ involvement in patients with acute gout 73
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List of figures

Figure 2.1: Acute flare affecting the 1st MPJ of the right foot 23
Figure 3.1: Flowchart of the literature search process 31
Figure 5.1: Disposition of study patients 55
Figure 5.2: Changes in tender joint count scores during and after
an acute flare 61
Figure 5.3: Changes in swollen joint count scores during and after
an acute flare 61
Figure 5.4: Changes in patient global scores during and after an
acute flare 62
Figure 5.5: Changes in C-reactive protein levels during and after
an acute flare 62
Figure 5.6: Changes in serum urate levels during and after an acute flare 63
Figure 5.7: Changes in FFI pain scores during and after an acute flare 64
Figure 5.8: Changes in LFIS scores during and after an acute flare 65
IF
Figure 5.9: Changes in HAQ-II scores during and after an acute flare 66
Figure 5.10: Changes in LLTQ ADL scores during and after an acute flare 66
Figure 5.11: Changes in LLTQ recreation scores during and after
an acute flare 67
Figure 5.12: Changes in LFIS scores during and after an acute flare 68
AP
Figure 5.13: Changes in FFI (disability) scores during and after
an acute flare 68
Figure 5.14: Changes in FFI (activity limitation) scores during
and after an acute flare 69
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Attestation of Authorship

“I Michael John Frecklington hereby declare that this submission is my own work and that,
to the best of my knowledge and belief, it contains no material previously published or
written by another person (except where explicitly defined in the acknowledgements), nor
material which to a substantial extent has been submitted for the award of any other degree
or diploma of a university or other institution of higher learning."

Student Name: ..................................................................................................................

Signature: ...........................................................................................................................

Date: ...................................................................................................................................
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Ethics approval
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