Gout is much more prevalent than many believe. One in 40 people in the UK live with the condition. Gout is the most common form of inflammatory arthritis worldwide. Treatment of gout must be quick and correct.

60% of the adult population in Ireland is classified as either overweight or obese. The prevalence of gout is so high in Ireland. Being overweight is a risk factor for gout, so it is of little surprise.

“Indeed, gout diagnoses are steadily increasing as is treatment of gout… particularly as the obesity epidemic progresses,” says Professor Geraldine McCarthy, Consultant Rheumatologist at the Mater Misericordiae University Hospital, Dublin.

“When the kidney is malfunctioning, it cannot remove uric acid from the body efficiently. This excess uric acid then accumulates in your joints as hard, needle-shaped crystals. These crystals inflame the lining of the joint (the synovium). The result is severe, painful swelling and redness of the joint”.

Breaking down the stigma and shame

Professor McCarthy believes more needs to be done to address the stigma around this painful and increasingly-common condition.

“Gout unfortunately has a stigma associated with it. The stereotypical individual with gout is one who is greedy. Consuming too much alcohol, eating too much rich food and is overweight,” says Professor McCarthy.

“Some people become embarrassed to go to the doctor as they feel it will reflect badly on them. Left untreated, gout can lead to joint and kidney damage, permanent disability. Similarly, it can cause an increased risk of death by heart attack or stroke.” Treatment of gout is essential.

Effective treatment of gout

Medication and lifestyle changes such as exercise, weight loss and cutting down on alcohol can reduce, or ultimately stop, recurrent gout attacks. However, Professor McCarthy highlights the need to avoid common misconceptions about treatment for gout. 

“It is incorrect that if you are receiving urate-lowering therapy (such as allopurinol or febuxostat) that you should stop the drug if you get an acute gout attack… even doctors get this one wrong sometimes,” she says.

Potential for misdiagnosis within treatment of gout

Often, people who report persistent pain in the big toe, without swelling and redness and have high uric acid in the blood are diagnosed with gout, when these symptoms could actually be osteoarthritis and not gout.Treatment of gout and osteoarthritis differs greatly.

The gold standard for diagnosis is to take a small sample of fluid from the affected joint and analyse it using a polarised-light microscope. Although the process is ‘very easy’, according to Professor McCarthy, misdiagnoses can still occur. 

Acute calcium pyrophosphate crystal arthritis or ‘pseudo-gout’ can cause similar attacks, but it’s calcium crystals that are deposited in the joint rather than urate crystals.

Professor McCarthy encourages patients to consult their doctor if they exhibit symptoms of gout. “If you don’t confirm what type of crystal it is, you can make the wrong diagnosis. This can lead to giving the patient the wrong treatment of gout.”

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Osteoporosis in Ireland is a disease that affects the insides of a person’s bones. In brief, it occurs when a person loses more bone than their body produces.

Osteoporosis in Ireland causes bones become brittle and break very easily – referred to as fragility fractures. Subsequently a person can look perfectly fine on the outside but have significant bone loss. There are no signs or symptoms prior to a person breaking a bone.

Everyone should check to see if they have risk factors for bone loss. Currently 280,000 people have been left undiagnosed.

One in four men and one in two women aged 50, will break a bone from osteoporosis in their lifetime.

Usually osteoporosis in Ireland is preventable in the majority of people, therefore most fractures are also preventable. People assume that breaking a bone is not serious. 20% of people aged 60+ who break their hip, will die within six-to-12 months, from the secondary effects of a fracture and 50% will lose their independence. 90% of fractured hips are due to osteoporosis.

Knowing what can help and prevent osteoporosis in Ireland

Many people confuse osteoporosis with arthritis. Osteoporosis affects the bones; arthritis affects the joints. 

Everyone should be getting the recommended daily amounts of calcium, vitamin D and protein, not only for their bone health but for their overall health. Appropriate weight-bearing exercise is essential to help build strong bones. Health professionals can interpret the DXA scan report from anyone with bone loss.

Those with bone loss are not recommended to be doing regular sit-ups, yoga, trampolining, or twisting their spine. Swimming and bike riding are not weight-bearing activities.

A personalised approach to treatment

There are approximately around 200 causes of bone loss and it is essential that these are investigated case by case. This is to ensure a person will improve on a chosen treatment and not continue to lose bone.

The treatment a person receives should be based on their age, their medical history, the results from a DXA scan of their spine and hips, if the person has broken a bone/s, the causes of their bone loss and the area/s affected. 

One in four men and one in two women aged 50, will break a bone in their lifetime from osteoporosis in Ireland, but it affects all age groups. Senior citizens are the highest risk group, as many are on medications or have conditions which cause bone loss.

Staggeringly, more women die from osteoporosis in Ireland, than the combined deaths of cancer of the ovaries, uterus and cervix. Similarly more men die from osteoporosis in Ireland, then get prostate cancer.

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Chartered physiotherapist, Dr Caitriona Cunningham, shares advice on how exercise and movement can benefit bones, joints and muscles. 

Top tips to keep health bones and joints

1. Movement and exercise are good for maintaining bone and joint health. This means sitting less, doing more general, everyday physical activity and participating in structured exercise programmes and sports.
2. Adults should aim to get at least 150 minutes of moderate intensity exercise per week. For example, very brisk walking or light cycling.
3. There’s always an exercise to suit – you just need to find the right type for you. Walking programmes suit a lot of people who just need to get started. It helps integrate exercise into a busy life on an ongoing basis.
4. Maintaining a healthy weight by combining a physically active lifestyle with a healthy diet will help prevent the overloading of joints, which can lead to joint pain and arthritis.
5. As we age, we lose bone and muscle mass. It’s recommended that adults train each major muscle group 2/3 days each week using exercises and equipment. Impact exercises (e.g. skipping, marching, running, jumping) are also recommended to prevent, and slow down loss of bone.
6. At work and in your home, consider ways that you can reduce the risk of joint and muscle problems. Move regularly and think before you lift – get assistance, or use lifting and moving equipment for heavier tasks. Consider how you can best arrange your work set up e.g. your desk, chair and computer.
7. If you have specific health issues, or a painful muscle or joint problem, you may benefit from the guidance of a physiotherapist to get you on the right exercise track.
8. Being active, taking exercise and maintaining a healthy weight are good for managing chronic joint and muscle pain. Expect muscle soreness when starting a new type of exercise.
9. Obviously, if you have an acute bone or joint injury it may require a health professional consultation. Combined with a defined period of taking it easy but it will be important to get moving again to achieve recovery.

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Tips and lessons on how we carry out everyday activities.

“We all know the basics of saving our back when it comes to lifting heavy items. But I would be remiss if I didn’t speak about it at all. Bend the knees and hips and keep the back straight, keeping your core tight and braced, helps too. Thanks to that technique being drilled into us the reality is now, nine times out of ten people present to chiropractors with back injuries that do not occur that way. Many back injuries seem to occur due to bending over to pick up a tiny item. For example, a piece of paper or putting something in a dishwasher.

Heavy lifting isn’t actually the main culprit for most back injuries, but why is that?

“Usually it is due to something that was done previously. More times than not it is maintaining the same poor postural position. This activity may have been done only once or repeated over the years. It takes time for the damage to the joints to manifest itself enough to cause pain. Did you ever go the movies and sit in the front row and get a neck pain?

Daily activities that are performed one sided are a big culprit, hoovering is a big one. Most people hoover with the same foot forward and their spine slightly twisted pushing the device back and forth. We need to switch the stance frequently. Try putting the hoover tube on the other side of the body, thus hoovering like you are opposite handed. Learn to use your non-dominant hand for everything (especially if your body is slightly twisted). This includes when painting with a brush, drilling a hole, holding a baby or shovelling in the garden. This will preserve the health of your spinal joints, otherwise you are putting undue stress on them like ringing a towel, repeat this activity day in day out and the damage occurs so slowly, you don’t realise it till you bend over one day to tie your lace.

“The World Federation of Chiropractic’s motto for this World Spine Day campaign is “Love Your Spine”, so let’s practice balanced posture when carrying out daily activities, to save our spinal joints.”

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1% of the world live with rheumatoid arthritis, that’s 21 million people: 45,000 of those live in Ireland.

Rheumatoid arthritis (RA) is a chronic progressive autoimmune disease. It also affects the synovial joints predominantly of the hands and feet, in a symmetrical distribution¹. Chronic inflammation results in progressive joint damage which as a result, can end in arthralgia, joint deformity, decreased functional ability, prolonged disability and sometimes premature death². In fact 1%³ of the world have RA. For this reason about 3 million people living with RA in Europe. Similarly, according to Arthritis Ireland, 45,000 people suffer from the disease in this country.

RA is twice as common in women as men and the usual age of onset is between 35-50 years. 

Rheumatoid arthritis was only distinguished from gout and osteoarthritis in 1922.However, it had featured in the paintings of artists in the seventeenth century.

Rheumatoid arthritis mainly affects the synovial joints, but many patients have extra-articular manifestations which can be serious. In particular, there is a substantial excess of infection and vascular disease; 50% of deaths in RA patients are attributable to cardiovascular disease resulting in heart failure, stroke and myocardial infarction⁴. These can shorten life expectancy anything from three up to 18 years^5.

Factors contributing to this increased risk include traditional cardiovascular (CV) risk factors. Hence, these included: age, gender, dyslipidaemia, hypertension, smoking, obesity and diabetes mellitis (DM), which partially explain the excess CV risk.

The need for more targeted treatment of cardiovascular risk

Comorbidities in patients with chronic diseases including RA have been shown to be under-recognised and under-treated with wide variability existing between countries with respect to their prevalence, detection and compliance with recommendations for prevention and management⁶. Guidelines published by EULAR advise aggressive management of these traditional risk factors with tight RA disease management to try and combat cardiovascular disease for these patients^7.

As our department is similar to others in Ireland, we are engaging with others in Galway and Sligo to examine RA and CV more closely. All of this work highlights a need for more targeted treatment of cardiovascular risk and has led us to consider establishing an ANP-led cardiac clinic here in Cork University Hospital to address this deficit.

^{1: Aletaha et al 2010  |  2: Scheinecker al 2008  |  3: Shapira et al 2010  |  4: O’Sullivan 2014
5: Solomon et al 2003  |  6: Dougadas et al 2014  |  7: Agca et al 2017}

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Musculoskeletal diseases in Ireland and the European Union are the most common cause of disability and work-related disability .

Musculoskeletal diseases in Ireland and the European Union are the most common cause of disability and work-related disability . The Global Burden of Disease study in 2012, showed the most common cause of disability worldwide today is lower back and neck pain. Disability related to musculoskeletal diseases has risen by almost 50% over the past 2 decades, while it is only 33% for other diseases.

It is estimated approximately 30,000 osteoporotic fractures occur each year in Ireland.  

A 2011 report states 40% of Irish adults experience chronic musculoskeletal pain, a number that is greater than the combined number of people with cardiovascular disease, chronic obstructive lung disease, diabetes mellitus and cancer.

An E.U. report on musculoskeletal diseases states governments and health authorities are unaware of the size of the problem, including the disability, lost productivity and economic burden.

Despite these statistics, funding for musculoskeletal diseases and research in North America and Europe is only a fraction of that provided for cancer and cardiovascular disease.

Osteoarthritis causes pain, stiffness, swelling and deformity of the joints, and most commonly affects hands, toes, knees, hips and back, however any joint can be affected. Treatment today consists of education, exercise, diet, pain control and occasionally surgery.

A recent survey of more than 600 Irish patients with moderate-severe arthritis, fibromyalgia and osteoporosis showed:

• 1 in 5 were disabled and 15% had taken early retirement due to their illness
• 60% stated their illness had moderate-severe impairment on their life
• 10% missed a medical appointment in the past year because they could not afford it
• 60% reported moderate-severe pain, and 30% reported depression.

What is osteoporosis?

Osteoporosis is a disease which results in loss of bone strength and structure making them brittle and prone to breaking. The medical term for a broken bone is a fracture. Osteoporosis does not result in any symptoms until a bone breaks, but when that happens the results can be devastating.

An American study published a decade ago, showed the annual risk of fracture for a post-menopausal woman, is greater than her annual risk of heart attack, stroke, death from heart disease and invasive breast cancer combined.

A 2017 report from the International Osteoporosis Foundation states Ireland has the 6^th highest rate of hip fracture in the world. A conservative estimate suggests approximately 30,000 osteoporotic fractures occur each year in Ireland.

How can we treat it?

1. A diet rich in calcium and vitamin D over the use of supplements
2. Fall prevention assessments  
3. Exercise programmes for strength, conditioning and weight-bearing  
4. Medications for those over fifty with fragility fractures or a T-score <-2.5 when indicated  
5. Surgery for some broken bones  
6. Identification and treatment of any underlying causes: e.g. arthritis, coeliac disease.

Why is early treatment and diagnosis so important?

There have been improvements over the past fifty years when it comes to osteoporosis. However, one in five Irish women and one in three men will die in the year following a hip fracture. It is not a benign disease. Of those who survive, many will end up confined to a nursing home and never regain their pre-fracture capacity and health.

Irish fracture liaison programmes have shown that more than 80% of such patients can be identified, diagnosed and treated. Every hospital and region needs these services to close the treatment gap and quality chasm.

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Physiotherapists can work with patients to decide on the most appropriate management for acute and long-term bone / joint pain. Similarly, they or help people who simply want advice about getting active.

GP’s may refer patients with body movement and function issues. Body threats can include age, injury, disease, joint and muscle conditions. This can be a misunderstood profession. As a result, some patients believing that physiotherapists simply offer manual  therapy. Or manipulation of affected areas and they may: yet physiotherapy is a much broader healthcare specialty than that.

“A physiotherapist takes a holistic view,” says Dr. Caitriona Cunningham of the Irish Society of Chartered Physiotherapists, the professional body representing over 3,000 Chartered Physiotherapists in Ireland. “Their role is to assess the individual, diagnosis and work together on deciding the most appropriate management for them. They may ask: is exercise the most appropriate approach in this particular case, at this point in time? Will this patient benefit from manual therapy or a joint injection?  Does this person need further investigations, and/or medications? They’ll be able to offer  treatment and advice for acute bone and joint pain based on current best evidence. Similarly, they can provide guidance on long-term bone and joint pain management – usually involving exercise. They also have knowledge of the appropriate referral pathways in the health system”

Self-management

Some people presenting to a physiotherapist with joint aches and pains may be diagnosed with arthritis or degenerative changes of their joints, says Cunningham. But if arthritis is diagnosed, a physiotherapist can help the patient self-manage the condition, even if it becomes chronic. “Some people need to see a professional to be empowered to manage their chronic conditions,” she says. “Physiotherapy can help do that, and so maximise function and quality of life.”

Yet physiotherapists don’t only offer treatment to those with acute or chronic pain. “They can also advise people who are feeling well to get active,” says Cunningham. “Increasing numbers of physiotherapists are focussing on health promotion and primary prevention. For example, if you want to take up exercise but are concerned about keeping your joints healthy, a physiotherapist can assess you and advise which exercises to do and which ones to avoid.”

Keeping active

In terms of bone health and osteoporosis, one role of the physiotherapist is to encourage young people to be active so that they can build bone strength and to advise people to engage in impact and strengthening  exercise  throughout their lives  to maintain  bone strength and muscle health.  “Some people avoid exercise, either on the basis that it might be bad for their joints, or that they have osteoporosis,” actually, we all experience muscle loss as we age and joint aches and pains are common  but it can create more problems if you don’t stay active. Yet you may need guidance from a physiotherapist to get you started.”

If you have any concerns about bone or joint aches or pains, you can contact a private physiotherapy  practitioner directly. However, the advice is to always see your GP first. And when you choose a physiotherapist, make sure that they are a  Chartered practitioner. As state registration of physiotherapists is on the way , this will provide greater transparency for members of the the public,  enabling them  to make more informed choices.

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Many people getting spinal fractures in Ireland are never treated for the underlying disease: osteoporosis. With this in mind, reasons include lack of knowledge and resources.

Mr John McCabe, Spine Surgeon at Galway University Hospitals, emphasises that early screening and diagnosis of osteoporotic fractures is vital.

“With people living longer, it’s inevitable that a high proportion will suffer from bone weakness. This means there’s an increase in people developing an acute, painful condition of the spine, where they develop a fracture. Osteoporosis isn’t purely an elderly disease – it can also effect anyone from young female athletes to active males.”

Balloon kyphoplasty is the key surgical procedure for treating osteoporotic fractures. Cement-like material is injected into the fractured bone, however, Mr McCabe, who is also president of the Irish Spine Society, explains that this is currently poorly supported in Ireland and access to spinal specialists with his level of expertise is low.

“Balloon kyphoplasty patients can expect a significant reduction in pain, an increase in their quality of life and maintenance of a normal lifestyle”. Mr McCabe, performed the first kyphoplasty procedures in the UK and Ireland 14 years ago. There have been over five million cases internationally over the last 15 years. In some countries it’s well-funded, but we are well behind.”

“The treatment is there. The need is there. But unfortunately the services aren’t. We need a structure that we can roll out in the Irish health service for people with these fractures. A simple pathway for family doctors and their patients. There needs to be a focus on it on a national level.”

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Pat Sheehan, principal consultant at BSM Galway, shares his experience of the balloon kyphoplasty procedure. He also discusses the stigma surrounding osteoporotic fractures and osteoporosis.

Fifty-two-year-old Pat Sheehan maintains a healthy and active lifestyle, enjoying jogging and regular games of golf. But when Pat was 37, he underwent surgery after having a heart attack. Now he receives ongoing treatment plans and monitoring to keep his heart healthy.

The discovery of osteoporosis shocked Pat. This severe case caused a fracture to his spine despite his otherwise healthy lifestyle.

“I felt sudden back pain last August.” Pat was two weeks into the Couch to 5k jogging programme. “I initially assumed it was muscle pain so I didn’t do much about it. About two weeks later, I was away on a golfing trip and was routinely swinging the golf club. A sharp pain in my back I experiences ended with an MRI scan.”

Osteoporosis diagnosis

Mr John McCabe, Spine Surgeon at Galway University Hospitals, confirmed to Pat that his MRI scan had indeed shown signs of a fracture of his L2 (second lumbar vertebra). But this wasn’t the result of any vigorous exercise. The underlying cause was severe osteoporosis.

Mr McCabe made me aware of the fact that younger people and younger men, like myself, do get osteoporosis.

“I’m 52 and I would have thought that osteoporosis is a disease that elderly women get. I didn’t expect to be diagnosed but Mr McCabe made me aware that younger people do get osteoporosis diganosis.

“After the scan, Mr McCabe was extremely helpful and suggested I undergo balloon kyphoplasty. It was under general aesthetic and an inserted balloon placed the bone back into the original position while added cement stabilised it. Thankfully it worked out very well. In two days after. Two days after, the pain I had been experiencing in my back was gone. I even went for a three-mile walk!”

This is one of the many benefits of balloon kyphoplasty – regular lifestyle routines don’t need to be sacrificed.

What you should do if you have an osteoporosis diagnosis

“I asked Mr McCabe how soon I could resume normal activities and he recommended weight-bearing exercise – exercises that work against gravity in order to strengthen the bone such as brisk walking.”

Although Pat does stand a significantly higher risk of future fractures because of his “extremely soft bones”, continuing to treat the underlying cause, osteoporosis, is crucial to avoiding these.

“I’m now under the care of an excellent rheumatologist, John Carey, and have a long-term treatment plan, including a daily injection of medication for two years and a further regimen of treatment afterwards. Mr McCabe advised if I ever got a pain in my back again, the first thing I should do is get an MRI and not assume that it is something else.

“This applies to anyone in a similar situation as me. If you have a persistent pain in your back and you can’t put your finger on what caused it, get an MRI scan to rule out an osteoporotic fracture or more sinister causes, such as cancer. I feel that there’s an unawareness among the general population of osteoporosis and the potential bone breakages and fractures that you can get as a result – you don’t need to be old, inactive or fragile for this to occur. So if my experience helps to raise awareness in this area, then that’s a great thing.”

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Ireland enjoys some of the best orthopaedic surgeons and healthcare in the world. But the difficulty to access it can be detrimental, one of the country’s leading experts denounces.

Professor John O’Byrne, Director of Masters Degree at the Royal College of Surgeons (RCSI), believes that there is much room for improvement in the way that bones and joints injuries are treated. This starts from the very first assessment where the accident took place.

Irish healthcare, when it can be accessed, is as good as anywhere else in the world. The standards of care are really high, but the problem is accessing the care.

“I often speak with surgeons who have done some training in North America, Canada, Australia. No matter where you go you find that we are in a good place. Not just for orthopaedic surgeons but for all members of the teams. We have a good healthcare when it comes to trauma.”

The problem with logistics

The problems may rise in the logistics of dealing with these injuries. “We need to improve the organisation of the trauma services. That means nominating some centres to taking more trauma than other centres,” says O’Byrne.

At the moment, the orders for an emergency response team are to bring the patient to the closest hospital. This is regardless of the type of injury that he or she may be suffering.

However, many hospitals do not have the right structures and facilities to work on this type of injuries.

Patients brought straight to a hospital where there is an orthopaedic surgeon have an improved mortality and morbidity rate. Research has shown this pretty conclusively.

O’Byrne says “one thing that we would like to see at the RCSI is that trauma patients are not sent to hospitals that do not have orthopaedic surgeons anymore,”. O’Bryne oversees the formation of more than 600 surgeons between the RCSI and the University College Dublin.

“It is not right for the patient. Nor is it right for the hospital. It is not right for the doctor who receives the patient. Research has shown that mortality and morbidity can be improved if patients are brought straight to a hospital where there is an orthopaedic surgeon.”

Bringing patients to the right orthopaedic surgeon, not the closest

“In the UK there has been a good rationalisation of trauma services. Population spread in Ireland is very different. Most of the population is around Dublin. But if you look at the trauma, they’re well spread around the country, and facilities differ from place to place.”

The issue is tricky, because it would bring responsibility to the ambulance team to assess where to carry a patient, and maybe choosing a hospital ahead of a closer one because the further one has better facilities. “We would never think of driving another hour with an injured patient, but if it is only 15-20 minutes, of course you would do it.”

“It is understandable the concerns that people have, and the reassurance everybody gets as soon as the patient reaches the hospital, but if the carers could bring them to the right hospital and not just the closest… it is just having a structure in place to allow them to do that.”

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