Background

Gout is the commonest inflammatory arthritis affecting around 1.4% of adults in Europe. It is predominantly managed in primary care and classically affects the joints of the foot, particularly the first metatarsophalangeal joint. Gout related factors (including disease characteristics and treatment) as well as comorbid chronic disease are associated with poor Health Related Quality of Life (HRQOL) yet to date there is limited evidence concerning gout in a community setting. Existing epidemiological studies are limited by their cross-sectional design, selection of secondary care patients with atypical disease and the use of generic tools to measure HRQOL. This 3 year primary care-based prospective observational cohort study will describe the spectrum of HRQOL in community dwelling patients with gout, associated factors, predictors of poor outcome, and prevalence and incidence of foot problems in gout patients.

Methods

Adults aged ≥ 18 years diagnosed with gout or prescribed colchicine or allopurinol in the preceding 2 years will be identified through Read codes and mailed a series of self-completion postal questionnaires over a 3-year period. Consenting participants will have their general practice medical records reviewed.

Discussion

This is the first prospective cohort study of HRQOL in patients with gout in primary care in the UK. The combination of survey data and medical record review will allow an in-depth understanding of factors that are associated with and lead to poor HRQOL and foot problems in gout. Identification of these factors will improve the management of this prevalent, yet under-treated, condition in primary care.

Background

Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care.

Methods

All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records.

Discussion

This three-year prospective epidemiological study will combine survey data, comprehensive clinical, x-ray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.

Gout is the most prevalent form of inflammatory arthropathy. Several studies suggest that its prevalence and incidence have risen in recent decades. Numerous risk factors for the development of gout have been established, including hyperuricaemia, genetic factors, dietary factors, alcohol consumption, metabolic syndrome, hypertension, obesity, diuretic use and chronic renal disease. Osteoarthritis predisposes to local crystal deposition. Gout appears to be an independent risk factor for all-cause mortality and cardiovascular mortality and morbidity, additional to the risk conferred by its association with traditional cardiovascular risk factors.

This invited paper provides a summary of a keynote lecture delivered at the 2011 Australasian Podiatry Conference. Gout is the most prevalent inflammatory arthropathy. It displays a striking predilection to affect the first metatarsophalangeal joint as well as joints within the mid-foot and ankle. A number of factors are known to reduce urate solubility and enhance nucleation of monosodium urate crystals including decreased temperature, lower pH and physical shock, all of which may be particularly relevant to crystal deposition in the foot. An association has also been proposed between monosodium urate crystal deposition and osteoarthritis, which also targets the first metatarsophalangeal joint. Cadaveric, clinical and radiographic studies indicate that monosodium urate crystals more readily deposit in osteoarthritic cartilage. Transient intra-articular hyperuricaemia and precipitation of monosodium urate crystals is thought to follow overnight resolution of synovial effusion within the osteoarthritic first metatarsophalangeal joint. The proclivity of gout for the first metatarsophalangeal joint is likely to be multi-factorial in origin, arising from the unique combination of the susceptibility of the joint to osteoarthritis and other determinants of urate solubility and crystal nucleation such as temperature and minor physical trauma which are particularly relevant to the foot.

Background.

Foot pain and related disability in older adults are common yet understudied problems. This study aimed to determine the onset and persistence of disabling foot pain in community-dwelling older adults over a 3-year period.

Methods.

A 3-year follow-up postal survey was conducted in a population sample of older adults aged 50 years and older, recruited previously as part of the North Staffordshire Osteoarthritis Project. Disabling foot pain was defined as the report of problems on at least 1 of the 10 function items of the Manchester Foot Pain and Disability Index occurring on most/every day(s).

Results.

Of persons without disabling foot pain at baseline, 8.1% had developed it at 3 years. Onset was greater with increasing age (50–59 years, 6.7%; 60–69 years, 9.1%; and ≥70 years, 9.5%; p = .037), in females (2.5% difference; 95% confidence interval 0.3%–4.8%), and in those with nondisabling foot pain at baseline than those without foot pain (14.2% difference; 95% confidence interval: 10.0%–19.1%). Persistence of disabling foot pain at 3 years was 71.7%, more common in females (9.3% difference; 95% confidence interval: 0.8%–18.0%) but not associated with age.

Conclusions.

Accelerated onset with increasing age and frequent persistence suggests considerable public health impact of disabling foot pain as the population ages. Prevention of disabling foot pain in later life should be prioritized and predisposing factors identified as potential intervention targets.

Objectives

To determine whether joints affected by gout are also affected by osteoarthritis (OA).

Methods

A postal questionnaire was sent to all adults aged over 30 years registered with two general practices. The questionnaire assessed a history of gout (doctor diagnosed, or episodes suggestive of acute crystal synovitis) and medication use. Patients who possibly had gout attended for clinical assessment to verify the diagnosis on clinical grounds and assess the distribution of joints affected by acute attacks of gout and OA. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated between the history of an acute attack of gout and the presence of OA at an individual joint adjusted for age, gender, body mass index and prior diuretic use in a binary logistic regression model.

Results

A total of 4249 completed questionnaires were returned (32%). From 359 attendees, 164 cases of gout were clinically confirmed. A highly significant association existed between the site of acute attacks of gout and the presence of OA (aOR 7.94; 95% CI 6.27, 10.05). Analysis at individual joint sites revealed a significant association at the first metatarsophalangeal joint (aOR 2.06; 95% CI 1.28, 3.30), mid‐foot (aOR 2.85; 95% CI 1.34, 6.03), knee (aOR 3.07; 95% CI 1.05, 8.96) and distal interphalangeal joints (aOR 12.67; 95% CI 1.46, 109.91).

Conclusion

Acute attacks of gout at individual joint sites are associated with the presence of clinically assessed OA at that joint suggesting that OA may predispose to the localised deposition of monosodium urate crystals.

Objectives

To assess concordance of the management of chronic gout in UK primary care with the European League Against Rheumatism (EULAR) gout recommendations.

Methods

A postal questionnaire was sent to all adults aged >30 years registered with two general practices. Patients with possible gout attended for clinical assessment, at which the diagnosis was verified clinically. Aspects of chronic gout management, including provision of lifestyle modification advice, use of urate‐lowering therapies (ULT) including dose titration to serum urate (SUA) level, prophylaxis against acute attacks, and diuretic cessation were assessed in accordance with the EULAR recommendations.

Results

Of 4249 (32%) completed questionnaires returned, 488 reported gout or acute attacks and were invited for clinical assessment. Of 359 attendees, 164 clinically confirmed cases of gout were identified. Advice regarding alcohol consumption was recalled by 59 (41%), weight loss by 36 (25%) and diet by 42 (29%). Allopurinol was the only ULT used and was taken by 44 (30%); 31 (70%) were taking 300 mg daily. Mean SUA was lower in allopurinol users than non‐users (318 vs 434 μmol/l) and was less often >360 μmol/l in allopurinol users (23% vs 75%). Eight patients had recently commenced allopurinol; two of these also were taking prophylactic colchicine or non‐steroidal anti‐inflammatory drugs. Of 25 patients with diuretic‐induced gout, 16 (64%) were still taking a diuretic.

Conclusion

Treatment of chronic gout is often suboptimal and poorly concordant with EULAR recommendations. Lifestyle advice is infrequently offered, and allopurinol is restricted to a minority. Persistent hyperuricaemia was often seen in allopurinol non‐users, but was also in allopurinol users, suggesting that doses >300 mg are often necessary.

Objective. To estimate the incidence of, and factors associated with, consultation for musculoskeletal foot problems in primary care.

Methods. Survey data from 13 986 people aged ≥50 years who took part in the North Staffordshire Osteoarthritis Project were linked to a database of primary care consultations. Foot problems were defined as responding affirmatively to the questions: ‘Have you had any problems with your feet over the last year?’ or ‘Have you had pain in the last year in and around the foot?’. The main outcome measure was a record of a musculoskeletal foot-related consultation within 18 months following the survey.

Results. Of the 3858 participants with foot problems who had not consulted before the survey, 350 (9.1%) consulted in the 18 months following the survey. Age, sex, education, general health and pain in other regions were not associated with future consultation. However, those who consulted were more likely to have reported foot pain [adjusted odds ratio (OR) 2.04; 95% CI 1.22, 3.42) and to consider treatments to be effective in controlling disease (OR 1.54; 95% CI 1.07, 2.21) in the baseline survey, and to have been a frequent consulter in the 18 months before the survey (OR 1.65; 95% CI 1.30, 2.09).

Conclusions. Only a minority of older people with musculoskeletal foot problems consult their general practitioner about them. Foot pain, frequent consultation for other problems and positive perceptions of treatment efficacy appear to be the strongest factors influencing future consultation.

Objective. Foot and ankle problems are highly prevalent in the general population; however, little is known about the characteristics of those seeking medical assessment for these problems. The objective of this study was to explore the extent and types of musculoskeletal foot and ankle problems in primary care.

Methods. Consultation data related to musculoskeletal foot and ankle problems in 2006 were extracted from the Consultations in Primary Care Archive (CiPCA), which covers consultations in 12 general practices in North Staffordshire. Data were cross-tabulated by age and gender, and annual consultation prevalence per 10 000 registered persons was calculated.

Results. Of the 55 033 musculoskeletal consultations documented in CiPCA in 2006, 4500 (8%) related to foot and ankle problems. The most commonly documented Read term was ‘foot pain’ (1281 consultations; 28%), followed by ‘ankle pain’ [451 (10%)]. Most consultations [3538 (79%)] involved non-traumatic conditions. Females accounted for slightly more consultations than males (55 vs 45%), and the highest proportion of consultations involved people aged 45–64 years (36%). The number of consultations per patient ranged from 1 to 11. Annual consultation prevalence was 290 per 10 000 registered persons and increased with age, reaching a peak in the 65- to 74-year age group (411 per 10 000 registered persons).

Conclusion. Foot and ankle problems account for a substantial number of consultations in primary care, and most frequently involve non-traumatic conditions. Further research is required to evaluate the factors that influence consultation for foot problems and strategies that general practitioners use to manage these conditions.

Background

Recent healthcare policy has shifted the management of musculoskeletal conditions in the UK away from secondary care towards Clinical Assessment and Treatment Services at the primary-secondary care interface. However, little is known about the outcome of patients with musculoskeletal conditions referred from primary care to Clinical Assessment and Treatment Services or how best to identify those patients at high risk of poor outcome in this setting. We describe the protocol for a twelve-month prospective observational study which aims to describe the outcome of patients referred to musculoskeletal and back pain services at the primary-secondary care interface and to develop simple prognostic measures to guide clinical prioritisation and triage.

Methods/Design

All patients referred over a twelve-month period from primary care to musculoskeletal and back pain clinics in the primary-secondary care interface Clinical Assessment and Treatment Service in North Staffordshire will be mailed a postal questionnaire prior to their consultation. This will collect information on quality of life, general health, anxiety and depression, pain, healthcare utilisation including medication use, occupational characteristics, and socio-demographics. At the consultation in the interface clinic, the clinical diagnosis, investigations requested, and clinical interventions will be recorded. Follow-up data for the twelve-month period subsequent to recruitment will be collected via mailed follow-up questionnaires at 6 and 12 months, and review of medical records.

Discussion

This twelve-month prospective observational study of patients referred to a musculoskeletal Clinical Assessment and Treatment Service will assess the management and outcome of musculoskeletal care at the primary-secondary care interface as proposed in the Musculoskeletal Services Framework.

Background

Joint pain, specifically chronic knee pain (CKP), is a frequent cause of chronic pain and limitation of function and mobility among older adults. Multiple evidence-based guidelines recommend exercise as a first-line treatment for all patients with CKP or knee osteoarthritis (KOA), yet healthcare practitioners' attitudes and beliefs may limit their implementation. This systematic review aims to identify the attitudes, beliefs and behaviours of General Practitioners (GPs) regarding the use of exercise for CKP/KOA.

Methods

We searched four electronic databases between inception and January 2008, using subject headings to identify studies examining the attitudes, beliefs or behaviours of GPs regarding the use of exercise for the treatment of CKP/KOA in adults aged over 45 years in primary care. Studies referring to patellofemoral pain syndrome or CKP secondary to other causes or that occurring in a prosthetic joint were excluded. Once inclusion and exclusion criteria were applied, study data were extracted and summarised. Study quality was independently reviewed using two assessment tools.

Results

From 2135 potentially relevant articles, 20 were suitable for inclusion. A variety of study methodologies and approaches to measuring attitudes beliefs and behaviours were used among the studies. Quality assessment revealed good reporting of study objective, type, outcome factors and, generally, the sampling frame. However, criticisms included use of small sample sizes, low response rates and under-reporting of non-responder factors. Although 99% of GPs agreed that exercise should be used for CKP/KOA and reported ever providing advice or referring to a physiotherapist, up to 29% believed that rest was the optimum management approach. The frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89%; physiotherapy referral 44%-77%) than reviews of actual practice (exercise advice 5%-52%; physiotherapy referral 13-63%). Advice to exercise and exercise prescription were not clearly differentiated.

Conclusions

Attitudes and beliefs of GPs towards exercise for CKP/KOA vary widely and exercise appears to be underused in the management of CKP/KOA. Limitations of the evidence base include the paucity of studies directly examining attitudes of GPs, poor methodological quality, limited generalisability of results and ambiguity concerning GPs' expected roles. Further investigation is required of the roles of GPs in using exercise as first-line management of CKP/KOA.

Background

There is currently no interval-level measure of foot-related disability and this has hampered research in this area. The Manchester Foot Pain and Disability Index (FPDI) could potentially fill this gap.

Objective

To assess the fit of the three subscales (function, pain, appearance) of the FPDI to the Rasch unidimensional measurement model in order to form interval-level scores.

Methods

A two-stage postal survey at a general practice in the UK collected data from 149 adults aged 50 years and over with foot pain. The 17 FPDI items, in three subscales, were assessed for their fit to the Rasch model. Checks were carried out for differential item functioning by age and gender.

Results

The function and pain items fit the Rasch model and interval-level scores can be constructed. There were too few people without extreme scores on the appearance subscale to allow fit to the Rasch model to be tested.

Conclusion

The items from the FPDI function and pain subscales can be used to obtain interval level scores for these factors for use in future research studies in older adults. Further work is needed to establish the interval nature of these subscale scores in more diverse populations and to establish the measurement properties of these interval-level scores.