D Y Patil Journal of Health Sciences

REVIEW ARTICLE
Year
: 2021  |  Volume : 9  |  Issue : 4  |  Page : 140--145

Impact of physical activity on gouty arthritis: A systematic review


Sakshi Shah, Sandeep Babasaheb Shinde 
 Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Science “Deemed To Be University” (KIMSDTU), Karad, Maharashtra, India

Correspondence Address:
Sandeep Babasaheb Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Science “Deemed To Be University” (KIMSDTU), Karad, Maharashtra
India

Abstract

Gout is a metabolic disorder characterized by hyperuricemia and abnormal depositions of urate around tissues and in and around joints, that is, tophi. Gout is a progressive disease, which, if not treated effectively, can make a person disable. The aim of this study was to systematically review the literature on impact of gouty arthritis on physical activity. We performed a systematic review for impact of gouty arthritis on physical activity. An inclusion criterion of the review was the physical activity for gouty arthritis. Comorbidities were associated with gouty arthritis and long-term manifestations. Physically active patients have shown significantly low uric acid levels and also have fewer gout flares as compared to physically inactive patients.



How to cite this article:
Shah S, Shinde SB. Impact of physical activity on gouty arthritis: A systematic review.D Y Patil J Health Sci 2021;9:140-145


How to cite this URL:
Shah S, Shinde SB. Impact of physical activity on gouty arthritis: A systematic review. D Y Patil J Health Sci [serial online] 2021 [cited 2022 Oct 6 ];9:140-145
Available from: http://www.dypatiljhs.com/text.asp?2021/9/4/140/351084


Full Text



 Introduction



Gout is a metabolic disorder characterized by hyperuricemia and abnormal depositions of urate around tissues and in and around joints, that is, tophi. It is a form of crystal-induced arthritis.[1],[2] Worldwide, there were approximately 41.2 million prevalent cases of gout, with 7.4 million incident cases per year. Gout is characterized by joint inflammation, pain, and it is more commonly seen in the first metatarsophalangeal (MTP) joint. Most studies show that gout is characterized by monosodium urate crystals in joint space but recent investigations have shown that deposition and chronic inflammation may be present in many individuals before the first symptom.[1],[3],[4],[5],[6]

There are mainly two types of gouty arthritis, namely acute and chronic tophaceous.

Acute gout is characterized by immense pain, redness, and inflammation frequently beginning at night or early in the night. An incident of acute inflammation is most commonly seen in synovial structures of the joint, tendons, and bursae, hence increasing acute arthritis, tendonitis, and bursitis.[3] In addition, gouty arthritis symptoms can recur, which can lead to urate crystals formation in the tissue and in and around joints, which is called chronic tophaceous gout. It is characterized by palpable tophi, joint range of motion limitation, continuous inflammation, and joint deformity.[1],[7],[8],[9]

In the early stage of disease mostly there is single structure involvement is seen and it is most commonly seen in MTP joint at the base of the big toe (34%). Other joints that are commonly affected are mid-foot, ankle (18%), and heel and knee joint (12%). Involvement of hands is also seen in long-standing gout. Polyarticular involvement can be seen in long-standing, untreated individuals (22%). Tophi were seen in one in each hand, elbow, and foot (8%).[3] Peripherally located structures are most commonly affected than central structures; the lower limbs are more commonly affected than the upper limb, whereas in long-standing gout can also affect the joints of axial skeleton.[3],[6],[7],[8],[10],[11]

Effect of gouty arthritis on physical activity

Gouty arthritis affects physical activity because development of tophi after long-standing gout but it can be seen as a first clinical manifestation in some patients. Most commonly palpable tophi are located in areas exposed to friction or pressure.[9]

Persistent joint range of motion limitation may be seen because of monosodium urate crystal deposition in either articular or periarticular structures, mostly ligaments, and tendons which alter joint biomechanics, which can lead to physical inactivity.[12],[13]

Joint inflammation is one of the main features of the gout. Joint inflammation is constant effusion caused by granulomatous inflammation of the synovial membrane. Persistent joint inflammation can further affect the joint condition.[13]

Osteoarthritis is the most prevalent joint disease which causes pain and disability. Gout is most common type of inflammatory arthritis which is associated with increased osteoarthritis knee prevalence and severity is most commonly seen among older men.[14],[15],[16]

Serum uric acid levels are associated and bone mineral levels are associated with bone density. Gout is associated with hyperuricemia and inflammation hence gout also increases the risk of osteoporotic fractures. In women history of gout is also associated with an increased risk of hip fracture. Women with old age, higher body mass index (BMI), less physical activity has a greater risk of fracture.[17]

The impairments in gouty arthritis rise with the presence of tophi and frequency of flares. Gout symptoms are also associated with an increase in impairments in daily activities. Gout is most commonly seen in the elderly population in whom arthritis, impaired gait, and eyesight problem increases the risk of fall, balance issue which may increase the related disability.[2]

Most frequently deformity develops late in the natural history of untreated gout. This causes structural damage to the joint structure which leads to deformity and loss of motion especially in the joints of hands and MTP joints. Painful movements of MTP joints can affect gait and can make walking difficult.[18],[19],[20] So footwear with good characteristics can reduce the plantar pressure and gait performance can be improved. Reducing the amount of weight bearing on the joints can also help in reduction of pain.[18],[21]

Risk factors for onset and development of gout

Age and sex

Generally prevalence of gouty arthritis increases with an increase in age due to aged people are prone to age-related diseases such as hypertension, decreased renal function and other age-related changes in the connective tissues may induce crystal formation.[2] It is more prevalent in men than women and overall prevalence is <1%. It is more also seen in post-menopausal women due to decreased estrogen.[11]

Diseases

There is a positive relation between gout and hypertension as patients with hypertension may have higher serum urate level. Metabolic diseases show a high risk of gout probably due to insulin resistance. Chronic kidney disease also shows positive relation with gout.[2] Approximately 80% of patients showed comorbid conditions with gout.[22],[23]

Lifestyle

Overweight and obesity are rising health issue and studies have found that there is a positive correlation between gout and BMI. BMI higher than 25 kg/m2 has a higher risk of gout.[24],[25]

Active range of motion, deep and vigorous massage may benefit and can improve the joint range of motion of the affected joint.[26] Inflammation around the joints can be reduced by cryotherapy and proper rest to the joint is required for prevention of further joint condition.[27],[28] As the gout flare subsides strengthening of proximal joints is necessary to reduce damage of affected joints and to avoid disability. Prolonged submaximal exercises also help in reducing or maintaining serum uric acid level.[29],[30],[31]

Disease-specific symptoms and associated comorbidities might negatively affect mobility, physical activity, and physical capacity of patients with gout.[30] Physical inactivity can cause accumulation of visceral fat which might increase the development of chronic disease in vicious cycle of chronic inflammation. The disorders can cause disability and reduced physical activity which further exacerbates inflammation.[32],[33] Skeletal muscles produce myokines during exercise which has anti-inflammatory effect for the patients. Exercises break vicious cycle of chronic inflammation and so reduce the deleterious effect of disease.[34]

 Materials and Methods



We performed a systematic review for impact of gouty arthritis on physical activity. Selected articles were based on authors’ expertise, knowledge, and reflective practice. For the purpose of the review, an electronic search for relevant articles using PubMed, PEDro, MEDLINE, and CINHAL database up to September 2021 was performed. In addition to electronic search, retrieved articles were searched manually for relevant studies. Following terms and free words were searched: “Gout,” “physical activity,” “and comorbidities.”

Study selection

A systematic review was done using studies that are published up to September 2021.

The inclusion criteria of the study were as follows:

  1. Physical activity for gouty arthritis


  2. Comorbidities associated with GA


  3. Long-term manifestations.


Data extraction

All steps in selection of studies were assessed for the inclusion criteria. The titles and abstract of the studies were reviewed by reviewers. Full text of related articles was reviewed and included if they met inclusion criteria. The following data were extracted from related articles: study design, study population, physiotherapy interventions, physical impact, selected outcome measures, and key findings.

Summary of included studies is given in [Table 1].{Table 1}

 Results



As shown in [Figure 1], the searches identified 10 relevant studies; these studies showed clinical manifestations of gouty arthritis in both acute and chronic phase and its impact on physical activity. There is a significant reduction in gout flare, inflammation, and pain in physically active gout patients. Some studies showed beneficial results of physiotherapy interventions in gouty arthritis and showed effects of exercise importance of judicious physical activities in gouty arthritis. Studies showed physiotherapy interventions reduce inflammation and also help in reduction of pain. Interventions also help to regain and maintain muscle strength and in prevention of further deformity.{Figure 1}

A study by Schlesinger et al.[35] stated that physically active gouts patients had over 12-folds fewer gout flare per year (P < 0.01), 10-fold less CRP (P < 0.01) and 2.8-fold decrease in perceived pain after 4-week period (P < 0.05) compared to physically inactive patients. There is a significant reduction in gout flare, inflammation, and pain in physically active gout patients.

A study by Howard et al.[25] was done to investigate the effect of exercise intensity and short-term training on alteration in plasma uric acid. In group one, subjects were cycled at 120% vo2max and another group was cycled continuously at 65% vo2max. Group 2 with prolonged submaximal exercise failed to stimulate increase in uric acid concentration (P < 0.05). The study concluded that exercise intensity rather than total work output is an important factor mediating the increase in blood uric acid concentration.

A study by Williams[25] shows that self-reported incident gout during 7.74 years of follow-up. The risk of gout increased with higher alcohol intake (P < 0.0001), meat consumption (P = 0.002), and BMI (P < 0.0001) and declined with greater fruit intake (P < 0.0001), running distance (P < 0.001), and fitness (P < 0.0001). Risk of gout was 16-fold greater for BMI > 27.5 than <20. Compared with the least active or fit men, those who ran >8 km/d or >4.0 m/s had 50% and 65% less risk of gout, respectively.

According to study of Safiri et al.,[36] approximately 41.2 million prevalent cases of gout were identified. This was a 7.2% increase (95% UI 6.4%, 8.1%) from 1990. Globally, gout accounted for 7.4 million incident cases (95% UI 6.6 million, 8.5 million), with an annual incidence rate of 91.8 (95% UI 81.3, 104.1), an increase of 5.5% (95% UI 4.8%, 6.3%) since 1990. Gout year lived with disease (YLD) amounted to nearly 1.3 million (95% UI 0.87 million, 1.8 million), with a rate of 15.9 YLD (95% UI 10.7, 21.8). This was an increase of 7.2% (95% UI 5.9%, 8.6%) from 1990 to 2017. The study concluded that the burden of gout is increased across the world.

According to a study by Khanna et al.[37] decreased health-related quality of life (HRQOL) was associated with more frequent gout flares and presence of tophi. Among the 27.7% of patients who were aware of their serum uric acid level, raised uric acid level and decreased HRQOL was associated with more flares and tophi. Outcome based on presence of tophi and number of flares, both flares (>4) and tophi (>1) were associated with decreased HRQOL (all P < 0.005). Gout flares are also associated with greater activity impairment.

Physically active patients have shown significantly low uric acid levels and also have less gout flares compared to physically inactive patients.

 Discussion



Gout is disease which not treated effectively the symptoms may worsen and it may require surgical interventions and hence timely physiotherapy interventions are important. In acute phase of gout physiotherapy interventions reduce inflammation, pain by using topical cryotherapy. Active motion of the joints, vigorous, and deep massage is the beneficial form of physiotherapy intervention for maintaining range of motion, regain and maintain muscle strength. Also studies showed long-term effects of gout and importance of judicious physical activities. Ice or mild heat, ultrasound and other electrotherapeutic modalities, shoe modifications or assistive devices that serve as a substitute for soft tissue are important for pain reduction and prevention of further deformity. Physiotherapy helps to prevent impairment caused due to disease and hence prevent physical inactivity which may worsen the symptoms of disease.[18],[21],[26],[27],[28],[30]

A study by Bolzetta et al.[2] stated that gout is a disease that represents itself more in elderly people, that is, people above 40 years as inflammatory arthritis and left untreated it can result in chronic progressive disease. It is more prevalent in men and the burden of disease increases particularly in old age people in whom arthritis, impaired vision and gait can enhance the condition and can make person disable. Early diagnosis and proper treatment are the important goal with the help of comprehensive geriatric assessment.

A study by Schlesinger et al.[27] was done to investigate whether physically active gout patients have lower pain scores, decreased inflammation, and less gout flares. Thirty gout patients were included in study aged between 31 and 86 (mean 61). According to the international physical activity questionnaire physically active and physically inactive patients was divided. C-Reactive protein level and rate of perceived pain at the time of visit were taken. Physically active gouts patients had over 12-folds fewer gout flare per year, 10-fold less CRP and 2.8-fold decrease in perceived pain after 4 week period compared to physically inactive patients. The study concluded that there is a significant reduction in gout flare, inflammation, and pain in physically active gout patients.

A study by Howard et al. was done to compare the effect of supramaximal and submaximal exercises on serum uric acid concentration. Two series of experiments were performed which include supramaximal intermittent exercise in six subjects with mean age of 21.5 and body weight of 74.5 kg and vo2max of 3.98 1.min–1. Each exercise session consisted of 1 min work with 4 minutes of rest performed until fatigue. Seven subjects with mean age of 20.9 and body weight of 70.4 kg and vo2max of 3.40 1.min–1 were participated in submaximal exercises. In both groups, short-term training was performed by repeating the exercise protocol for three consecutive days. In group one, plasma uric acid level was elevated on the first and second day and showed a further 23% increase with exercise. Group 2 with prolonged submaximal exercise failed to stimulate increase in uric acid concentration. The study concluded that exercise-induced alterations in serum uric acid level are related to the intensity of exercises rather than work output.[31]

A study by Khanna et al.[37] revealed that decreased health-related quality of life (HRQOL) was associated with more frequent gout flares and presence of tophi. Gout flares are also associated with greater activity impairment. Patients with self-reported gout were selected based on inclusion criteria and were categorized into manually exclusive groups based on gout flares experienced in the past 12 months. Current presence of tophi and serum uric acid level and health-related quality of life and activity impairment were compared across groups. Most patients were males and reported at least one gout flare in a year. Decreased HRQOL was associated with more frequent flare and presence of tophi.

A study by Channa and Siddalingamurthy[3] was done to determine the epidemiology, clinical presentation, and comorbidities associated with gout. There were 56% of men and 44% of women with mean age 52.11 years and mean body mass index 28.08 kg/m2 were affected with gout. Precipitating factors like alcohol intake were present in 66% of people. Comorbidities like obesity, hypertension, and cardiovascular diseases were present in 80% of people. The study stated that it is important to screen patients with gout for cardiovascular risk factors and comorbidities to improve the quality of life of patients and patient outcomes.

A study by Kelley et al.[29] was done to determine the effect of community deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases. The inclusion criteria of the study were adults with age more than 18 years with rheumatoid arthritis, osteoarthritis, fibromyalgia, lupus, gout, and ankylosing spondylitis. Thirty-three studies were included. Statistically significant improvement in pain and physical function was seen. The study concluded that community deliverable exercise improves pain and physical function in adults with arthritis and other type of rheumatic disease.

In a study by Kakutani-Hatayama et al.,[30] lifestyle factors that influence serum uric acid levels, risk of gout flares, and how to reduce deleterious effect was reviewed. The study concluded that weight reduction caused by daily exercise and limited intake of calories is recommended as the obesity increases uric acid levels and weight gain increases the risk of gout.

A study by Williams[25] was done to identify risk factors for gout in ostensibly healthy, vigorously active men. In the study gout was compared with baseline diet, body mass index (BMI; in kg/m2), physical activity (in km/d run), and cardio-respiratory fitness (in m/s during 10-km footrace) approximately in 28,990 male runners. The risk of gout increased with higher alcohol intake, meat consumption, and BMI, and declined with greater fruit intake, running distance, and fitness. Men who consumed 15 g alcohol/d had 93% greater risk than abstainers, and men who averaged 2 pieces fruit/d had 50% less risk than those who ate 0.5 fruit/d. Risk of gout was 16-fold greater for BMI 27.5 than 20. Compared with the least active or fit men, those who ran 8 km/d or 4.0m/s had 50% and 65% lower risk of gout, respectively. Lower BMI is related to the risk reductions associated with distance run and fitness. These findings conclude that the risk of gout is reduced in men who are more physically active, maintain ideal body weight, and consume diets enriched in fruit and limited in meat and alcohol.

Even though there are data available for impact of gouty arthritis on physical activity, there is very limited data available regarding the phase-wise impact of gouty arthritis on physical activity. The burden of gout is increasing across world. Our findings highlight the need of different exercise interventions for all age groups and need of educational program that describe gout, its risk factors, consequences, and its early effective management. Future recommendation would be studies to be conducted regarding specific exercise protocols and duration of the same. There are less data available for age-wise intensity of physical activity and proper structured program for same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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