Hyperuricaemia is a higher than normal blood level of uric acid. There are individuals with high blood uric acid levels and have never had an attack of gout. Are these people at risk of arthritis of the joints and kidney stones from urate crystals deposits? Yes they are.

Firstly the diagnosis of asymptomatic hyperuricaemia is made more frequently because of more screening, and blood tests for insurance purposes. Secondly you can break it down to primary and secondary types. In the primary type there may be a genetic link. In this case there is a deficiency of an important enzyme leading to excess production of uric acid. When this is severe (Lesch-Nyhan Syndrome), there are severe problems.

Secondary hyperuricaemia results from factors affecting the production and/or elimination of uric acid. These include medical conditions, drugs, metabolic conditions, obesity and alcohol consumption.

Sometimes hyperuricaemia is suspected when patients present to the doctor with tophi. These can be acute or chronic. An acute tophus is usually small and later soften when it becomes chronic. They look like small nodules and as they grow bigger, the skin overlying them looks shiny and feels smooth. Sometimes they can ulcerate and release white chalky stuff. If the patient is treated with allopurinol the tophi usually becomes smaller.

Dr. Phil Hariram

Arthritis Guide.

In the days before adequate treatment controlled the blood level of uric acid, chronic gout presented with multiple joint involvement and chronic poly-arthritis. Today this is rare and only found in patients who refuse medication, have poor compliance or unable to take suitable medication.

Here the acute gout attack will become more frequent. Then other joints become involved. The crystals deposited in and around the joints are needle shaped and I suspect this is why acute gout is so painful.

I had an elderly patient who had heart failure and was on large doses of diuretics and ace inhibitors. She developed acute gout. Her medication was looked at and altered. Unfortunately her uric acid level remained very high. She was started on allopurinol.

She developed an allergic rash to allopurinol. In fact everything the consultant prescribed gave her problems. In the end she had no medication and refused any attempt to try anything for her gout because she was worried about side effects.

She was put on a specific diet. Eventually she developed poly-arthritis. Her fingers had big nobbles for joints and she had problems walking around her ground floor flat. Tophi developed first on the ear then elsewhere.

A joint badly damaged by chronic gout will on x-ray show erosions, secondary calcium deposits and soft tissue swelling.

Allopurinol is the drug of choice in chronic gout. By maintaining the blood level of uric acid within the normal range, separation of urate crystals into joints and kidneys are prevented.

Dr. Phil Hariram.

Arthritis Guide.

The first explanation of podagra was in the sixteenth century by Burgamer, a German Physician. He said podagra is a pain in the feet with or without swelling which comes from dampness or drought.

Podagra is acute gout affecting the big toe and typically the first metatarso-phalangeal joint. It is as a result of higher than normal uric acid in the blood. Uric acid is mainly excreted by the kidneys.

Diuretics and other drugs can affect the function of the kidneys and reduce excretion of uric acid. This can cause elevated level of uric acid in the blood and acute gout.

Over indulgence in alcohol can trigger acute gout. Beer is the worse alcoholic beverage for gout. Port was linked to gout in the eighteenth century. At the time, port was stored in lead lined casks and lead diffused into the port.

Lead in the consumed port accumulated in the body and in the kidneys, it affected the ability of the kidneys to excrete uric acid. The imbalance caused high uric acid in the blood. This condition is called Saturine gout.

Sometimes podagra can develop following initiating treatment with allopurinol. Gross over eating especially seafoods and red meat can trigger podagra.

No one knows exactly why podagra is the commonest manifestation of acute gout. Some suggested that the first metatarso-phalangeal is used a lot and takes a lot of the body’s weight when walking.

Dr. Phil Hariram,

Arthritis Guide.

Gout develops when the level of uric acid in the blood stream is higher than normal. When this happens urate crystal are deposited in and around the joints.
There are two types of gout, primary and secondary. The body eliminates uric acid from the blood naturally and most of this (66%) is done by the kidneys. In primary gout the process of elimination is slow and as a result the uric acid level in blood remains higher than normal. This is called hyperuricaemia.

In this condition the level of uric acid in the blood gradually increases over several years and during this time there are no gout symptoms. In addition it is estimated that only 5% of people with high blood level of uric acid develop gout.

Secondary gout is as a result of other diseases or factors that can elevate the level of uric acid. Often it is the case that these diseases or drugs make the body produce uric acid faster than the body can eliminate it.

Drugs that can raise uric acid level are diuretics especially thiazides,low dose aspirin,pyrazinamide and cytotoxic drugs.

Medical conditions that can trigger gout include kidney disease, myxoedema, psoriasis, lead poisoning, sarcoidosis, obesity, myeloproliferative disorders and polycythaemia.

People on very strict (almost starvation) diet can have high uric acid levels. Hyperlipidaemia is associated with high uric acid level.

Urates are eliminated mainly by the kidneys. The renal tubules are the important part of the kidneys for excretion of uric acid. So anything that can affect the efficient functioning of the renal tubules can affect the level of serum uric acid.

Dr. Phil Hariram,

Arthritis Guide

Gout is a form of inflammatory arthritis. In gout, crystals of uric acid is deposited in and around the joints. For this deposit of urate to occur, the circulating level of uric acid in the blood must be higher than normal.

Gout has been recorded through the centuries. Hippocrates wrote about it and urate crystals were found in the big toe of an Egyptian mummy.

Gout is more prevalent in males and high in affluent societies. This may be a dietary factor. In the old days the rich ate the expensive red meat while the poor could only afford grain. Guess who developed gout?
Acute gout is rare in pre-menopausal women and it is predominantly a male disease up to the age of 50. It usually starts after 30 years of age and more commonly between 40 and 50 in males. In women the first attack is usually between 50-60 years.

The first attack of gout is usually in the big toe and this is called Podagra. 70-90% of first attacks present this way.

Pain often develops at night and within a few hours the pain level can escalate to severe and throbbing. The big toe will become red, hot, swollen and very tender to the touch. This acute attack will resolve spontaneously but can take weeks. Medical intervention often shorten this episode.

After this first attack your doctor is not likely to start you off on long term medication because you may not get another attack for years. On the other hand, you could have another attack in days.

Dr. Phil Hariram,

Arthritis Guide.

Magnets were discovered in China and Greece. In China it was used in fortune telling and as a guide to building. By 1200 AD they were used in ships as compasses. Ever since, sailors and navigators have used compasses and the earth’s magnetic field to guide them in their journeys, whether on land or at sea.

Legends have it that Magnes, the Greek shepherd discovered the magnetic properties of lodestone when his iron staff was stuck to the lodestone and he was unable to dislodge it. Another legend has it that magnets were discovered in Magnesia, a place in Turkey.

Traditional Chinese Medicine which dates back to 2600 BC used magnetic stones on certain areas of the body to correct imbalance. The Vedas, dating back to 1500 BC, mentioned the use of lodestone in healing. The dead were buried with the head facing north to create harmony between the body and the earth.

Thales, a Greek philosopher, described the magnetic effects of lodestone in the seventh century BC. When St. Augustine arrived in Britain in the sixth century, he noted that lodestone was being used.

Compasses were developed where the lodestone was suspended by a piece of string, then later by a piece of wood in water. This was subsequently replaced by the dry suspension magnets.

In 1269, Pierre de Maricourt mapped the magnetic field around the lodestone. William Gilbert in the sixteenth century recognised the two poles, north and south. He also described the healing properties of magnets. Gilbert realised that iron rods left in a north south direction in alignment with the earth’s magnetic field, became weakly magnetised after 20 years. He suggested that lightning could magnetise iron. He also found that if a blacksmith heated an iron rod, and cooled with the rod lying in a north south direction, it becomes magnetised if the blacksmith hammered it while it is cooling.

The horseshoe magnet was developed by bending a straight iron magnet into the shape of a horseshoe. With the north and south poles so near to each other, the power of the magnet was doubled.

Iron magnets were heavy. Lightweight powerful magnets were soon developed. In the eighteenth century, carbon steel magnets were developed. It retained its magnetism better than beaten iron.

The first alloy containing magnet was developed in the early twentieth century and contained cobalt, tungsten, molybdenum or chromium. The next development was in the 1930s when iron was alloyed with aluminium, nickel and cobalt. These magnets were called Alnico magnets. These magnets were still metal based and therefore heavy to use.

In 1980s, magnets incorporating cobalt and samarium were used. They were the rare earth magnets. They were lighter and were used in industry. They were, however, expensive. In 1983, magnets using iron, boron and neodymium were produced. They were called Neodymium Magnets. They are very difficult to demagnetise and will remain magnetised for several decades. The process by which neodymium magnets were developed is called sintering. High temperature and pressure are applied to the powdered metals. This, however, means the magnets are brittle but this can be overcome by using a strong metal casing. A Neodymium magnet of say 8000 gauss weighs 20 gm while the comparable strength Alnico magnet weighs 90kg.

In the nineteenth century, Hans Christian Oersted, professor of physics at Copenhagen discovered that an electric current developed a magnetic field. In 1830s Michael Faraday and Joseph Henry independently discovered that a magnetic field produced electricity.

James Clerk Maxwell, a British physicist developed the Cork Screw Rule for calculating the direction of electrical flow when an object is moved in a magnetic field. In 1820 Andre Marie produced a mathematical relationship between electricity and the strength of the magnetic field.

Franz Anton Mesmer was the eponymous Viennese psychiatrist who developed the theory of animal magnetism. In his magnetic seances, Mesmer placed individuals in a magnetic tub, and made them relax. He then touched them, sending them into a trance. When they woke up, they were cured.

Pierre Curie discovered that magnets lose their magnetism above a specific temperature. This is now known as the Curie point. Edward Purcell & Flix Bloch developed a way to measure the magnetic field of nuclei. This led to the development of the MRI (Magnetic Resonance Imaging) scan.

In the 1960-1970 superconductors were developed. Magnets were cooled to absolute zero. These magnets can generate fields up to 200,000 gauss. It is used today in nuclear research.
Dr. Phil Hariram.

Arthritis Guide.

There are many arthritic patients and sufferers in pain that use magnets. Some are very certain that the magnets they are using are a great help.

There are no large controlled clinical trials to evaluate the benefits of magnets on arthritis.

Doctors in general do not think they work to relieve pain in arthritis. There are, however, amazing anecdotal evidence. There are stories that seem too good to be true.

A friend of mind, Steve, has severe back problems. He has a prolapsed intervertebral disc.
He could not stand for long and often made his journey to the toilet on all fours. After a MRI scan and other tests, his orthopaedic Surgeon told him he needed surgery.

A friend introduced him to magnotherapy. He placed a powerful booster magnet directly over the prolapsed disc. Within a week he was up and about. Today he wears a magnetic bracelet and although his disc is still out, he can do most things with care.

Experts think that a magnet placed over an artery will improve the oxygen carrying capacity of blood. This encourages faster healing. This theory is used in horse racing. Injured horses are fitted with magnets to speed up recovery and get them back on the track in the quickest time possible.

The most recent trial results showed that there was no real benefit from using a magnetic bracelets. The only benefits were placebo effect. The proponents argue that the improvements in animals confirm the benefits are not just placebo. They site circumstances where animals have made significant improvements after a magnet was fitted. A dog that needed to be lifted up unto the back of the car was able to leap in after having a magnetic collar, and many more similar stories.

Magnets are safe to use. The drugs that are used to help control pain and stiffness in arthritis come with risks. Often with magnets from a reputable company you get your money back within a specified time. If it does not work send it back.

The new alloy deodymium magnets retain their magnetic properties for 100 years. So one magnet will last a like time as long as you do not lose it.

Trial Results.

Here is a brief summary of a trial result published in the British Medical Journal (BMJ).

Randomized controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee.

Tim Harlow, Colin Greaves, Adrian White, Liz Brown, Anna Hart, Edzard Ernst

BMJ 2004;329 (18 December), doi:10.1136/bmj.329.7480.0-b

Abstract

Objective: To determine the effectiveness of commercially available magnetic bracelets for pain control in osteoarthritis of the hip and knee.

Design: Randomized, placebo controlled trial with three parallel groups.

Setting: Five rural general practices.

Participants: 194 men and women aged 45-80 years with osteoarthritis of the hip or knee.

Intervention: Wearing a standard strength static bipolar magnetic bracelet, a weak magnetic bracelet, or a non-magnetic (dummy) bracelet for 12 weeks.

Main outcome measures: Change in the Western Ontario and McMaster Universities osteoarthritis lower limb pain scale  (WOMAC A) after 12 weeks, with the primary comparison between the standard and dummy groups. Secondary outcomes included changes in WOMAC B and C scales and a visual analogue scale for pain.

Results: Mean pain scores were reduced more in the standard magnet group than in the dummy group (mean difference 1.3 points, 95% confidence interval 0.05 to 2.55). Self reported blinding status did not affect the results. The scores for secondary outcome measures were consistent with the WOMAC A scores.

Conclusion Pain from osteoarthritis of the hip and knee decreases when wearing magnetic bracelets. It is uncertain whether this response is due to specific or non-specific (placebo) effects.

Dr. Phil Hariram,

Arthritis Guide.

If you have arthritis and you are looking to control pain without drugs, then the first thing you need to do is to  reduce your weight or maintain a normal weight. If you are overweight, weight loss will be the most important thing you can do to improve the level of pain, stiffness and mobility.

A small amount of weight loss can make a significant difference. The best measure of weight in relation to height and general body health is the Body Mass Index (BMI). The normal range is 20-25 and 26-30 is considered overweight and over 31 obese.

Extra weight puts additional stress on weight bearing joints such as knees and hips, and increases the level of pain. It also increases the risk of arthritis. It is not always easy to lose weight if you have arthritis.

If your weight remains constant on a particular diet plan, then you are consuming just the right amount of calories to provide for the needs of the body. If you are gaining weight, then you are taking more than your body needs and the extra calories are stored as fat.

To lose weight you need to consume less than your body requires. This way the extra calories needed is obtained from the breakdown of fats stored in the body. Exercise will help you burn fats. It is not as effective as a specific diet plan but will help. It should be incorporated into the whole weight loss plan.

The heavier you are, the more calories you will burn during exercise. Exercise will keep the joints supple, reduce stiffness and tone up supporting muscles. It also makes you feel healthier and energised.

When exercising, you are moving synovial fluids around the joint. This is beneficial because it improves nutrition to the joint.

To assess your progress, evaluate the level of pain, stiffness and mobility before your diet and exercise plan, then make assessments at intervals.

Dr. Phil Hariram

Arthritis Guide.

At the American College of Rheumatology Congress, reassuring information was released on repeat treatment of rheumatoid arthritis by MabThera or Rituxan (rituxmab). Further improvement of quality of life was achieved by a second course of rituximab.

Professor Keystone, University of Toronto, Canada said, “With further analyses, we are able to evaluate just what MabThera can deliver with subsequent treatment courses for patients who have an inadequate response or intolerance to one or more TNF(Tumour Necrotic Factor) inhibitors. Patients are telling us they feel better and their quality of like has improved significantly. This is supported by clinical outcomes.”

156 patients who had poor response to Tumour Necrotic Factor inhibitors were given MabThera. The second course showed further improvement of rheumatoid activity and remission.

Rituximab is a monoclonal antiboby that specifically acts on B-cells. B-cells are important in the inflammatory process of rheumatoid arthritis.

Rituximab was approved by the FDA in 1997 for the treatment of B-cell non-Hodgkin Lymphoma.

Adverse effects were reported to be fever, nausea, headache, weakness and chills.

There has been reports of serious side effects on infusion treatment with this drug. The manufacturer, Genentech Inc. reported 70 cases of serious infusion reactions in 12,000 to 14,000 patients on rituximab.

Dr. Phil Hariram.

Arthritis Guide.

Cervical spondylosis is a degenerative condition of the cervical spine.

Thirty five percent of us have had neck pain at some time or other but in most of us the pain was transient and disappeared in time. In some cases, however, this is not the case.

Movement of the neck is a complicated process involving the bones of the cervical spine, ligaments and muscles. It is not surprising that the neck is susceptible to injury and pain.

X-ray confirms the bony problem resulting in pain but a curious finding is that 80% of patients with no symptoms had abnormalities on x-ray, and it is not unusual to see x-ray abnormalities in the neck in the over 30s.

A common cause of neck pain is cervical spondylitis. This is like arthritis of the spine in the neck. Bony growth develops on the vertebral bodies. They are called osteophytes and the moving joints may become involved. There may also be intervertebral disc degeneration.

Progressive arthritis might lead to pressure on the nerves and the artery (the vertebro-basilar artery). This can lead to problems with swallowing, visual problems and vertigo.

With cervical spondylitis, pain is present. There may also be referred pain in the face and chest. There may be restriction of movement, pain on movement of the neck and stiffness.

Cervical spondylosis is more common in the lower cervical vertebrae but can be in the upper spine. In this case a patient can develop headache mainly in the back of the head (Occipital).

Dr. Phil Hariram.