Revision as of 12:11, 4 June 2015

A contribution by: Biterys Thomas, Crauwels Nick, Dedoncker Axel, Muylle Teun, De Cremer Wesli, Gonzalez Miguel, Pauwels Gertjan and Lippens Wout

 Original Editor Wout Lippens Top Contributors - Marie Avau, Debby Decock, Admin, Evan Thomas, Kim Jackson, Wout Lippens, Oyemi Sillo, 127.0.0.1, Thomas Bilterys and WikiSysop  

Search Strategy[edit | edit source]

Databases searched: Pubmed, PEDro, eMedicine, Medscape, Cochrane Database
Keywords searched: Atlantoaxial osteoarthritis, atlanto odentoid osteoarthritis, upper cervical osteoarthritis AND treatmant, physical therapy, physiotherapie

Definition/Description[edit | edit source]

Atlantoaxiale Osteoarthritis is a metabolically active, dynamic process that involves all joint tissues such as cartilage, synovium/capsule, ligaments and muscles. It refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of lifeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.(Level of evidence 5, Level of evidence 1B) Atlantoaxiale osteoarthritis can be divided into idiopathic degenerative and posttraumatic osteoarthritisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title .(Level of evidence 3A, Level of evidence 4)

Clinically Relevant Anatomy[edit | edit source]

The cervical spine consist of seven vertebrae. The first two vertebrae are the atlas (C1) and the axis (C2). They form a joint structure which is called atlantoaxial joint. This joint is responsible for 50% of all cervical rotation. Regarding anatomical structure and function, the two upper vertebrae differ from the five other cervical vertebrae. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(Level of evidence 5)

The atlas (C1) doesn't have a corpus and is ring-shaped. It has a thick arcus anterior, a thin arcus posterior, two prominent massae lateralis, and two processus transversi. On each massa lateralis are two facets: a superior facet (with the facies articularis superior) and inferior facet (with the facies articularis inferior). The concave, kidney-shaped superior articular facets (facing upward and inward) articulate with the downward and outward facing facets of the occipital condyles. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The axis (C2) has a corpus vertebrae which contains the dens (odontoid process of the axis). This vertebra has five facies articularis: two superior, two inferior and one facies articularis anterior. The facies articularis anterior is found on the anterior aspect of the dens and articulate with the fovea dentis of the atlas. The facies articularis superior of the axis articulate with the facies articularis inferior of the atlas. The facies articularis inferior articulate with the facies articularis superior of the third cervical vertebrae (C3). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The ligamenta alaria, apicis dentis, transversum atlantis provide stabilization and prevent posterior displacement of the dens in relation of the atlas. The ligamentum transversum atlantis holds the dens tight proximity to the posterior part of the anterior arch of the atlas. These ligaments still allow spinal collum rotation. Internal and external ligaments reinforce the craniocervical junction (atlanto-occipital joint), the lower atlanto-axial joint and other cervical segments. The surrounding postural muscles and the ligaments secure the spinal stability of the cervical spine and allow cervical motion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

(See Atlanto-axial joint for more information.)

Epidemiology /Etiology[edit | edit source]

Idiopathic osteoarthritis occurs in the elderly, where posttraumatic osteoarthritis occurs more often in the younger population. It has a prevelance between 4 and 8%Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title . Only a minority of patients become symptomatic. Most (symptomatic)patients are female (74%) presenting with a unilateral osteoarthritis,wich is typically triggered by rotation and can ascend to the occiput and towards frontal.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The prevalence of osteoarthritis of the atlanto-odentoid joint is higher when people get older. Liu et al. found that the rate of osteoarthritis was 16% in the age group 18-25 years, 23% in the age group 25-30 years, 33% in the age group 30-40 years, 54% in the age group 40-50 years, 70% in the age group 50-60 years, 87% in the age group 60-70 years, and 93% in the age group >70 years. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In addition, the severity of the osteoartritis increases with age.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Prescene or severity of ostearthritis of the atlanto-odentoid joint is not gender dependant.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2B, Level of evidence 2B)

The incidence of atlanto-odontoid degeneration is very high in patients who had an odontoid fracture but it's remarkable that the lateral atlantoaxial joints are relative spared.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleHead loading is also a known cause of degeneration affecting the occipito-cervical region. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2B)

The severity of symptoms do not seem to correspond with the severity of the atlanto-axial osteoarthritis. In a study of Badve et al. there is no statistically significant association between presence of radiologic changes in male porters and their symptoms. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title According to Betsch MW et al. degeneration is associated with dens fractures, therefore cervical spine radiographs should be assessed for changes of atlantodens and atlanto-axial facet joints. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Characteristics/Clinical Presentation[edit | edit source]

Osteoarthritis of the atlantoaxial joints has been recognized as a distinct cause of occasionally severe occipitocervical pain in the elderly.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Degerative changes of atlantodens and atlanto-axial facet joints can contribute to pain and motion limitations. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Patients typically complain about unilateral neck pain occurring with the slightest head rotation. The pain ascends unilaterally to the occiput, the parietal skull and sometimes even to the eye. Patients also report visual problems often leading to an ophthalmologic work up. They also frequently report a painful audible crepitation with head rotationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title . Pain reduces functional status by causing spasm in the surrounding muscles and by limiting the range of motion (ROM) of the neck, especially in the plane of axial rotation of C1-C2Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Differential Diagnosis[edit | edit source]

Common:Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Cervical strain
Acute whiplash

Uncommon: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Rheumatoid arthritis
Cervical facet syndrome
Spasmodic torticollis
Cervical fracture (Jefferson fracture, Odontoid fractures, Hangman's fracture)
Cervical dislocation
Cervical radiculopathy
Cervical Myelopathy
Cancer: Metastatic or primary
Meningitis
Vertebral osteotomy
Epidural abscess

Because of the rare prevalence, degenerative fibrosis of atlantoaxial osteoarthritis can be confused with other pathologic entities, such as rheumatoid fibrosis, tumors and migrated disc herniation.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Also important is that atlantoaxial joint osteoarthritis should be considered in the differential diagnosis in elderly patients examined for neck pain with or without progressive quadriparesis.
The identification of a periodontoid ligamentous degenerative mass suggests the presence of instability of the atlantoaxial joint.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Diagnostic Procedures[edit | edit source]

Clinical evaluation should start with: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The medical history wich includes: the type, the start, the location and duration of symptoms, joint function, medical condition patient, medication, other treatments, family history, things that cause or aggravate pain, red flags… Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Physical examination includes: Range of motion tests, evaluation of spinal joints, nerve tests, reflexes, active examination, ...
Medical imaging and examination: X-rays can identify degeneration of joints, the presence of trauma, and bone related disorders. However, radiologic findings of osteaoarthritis do not corrolate to the severity of the osteoarthritis and associated symptomes. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Radiology, autopsy, conventional computed tomography and multidetector computed tomography can be used to examine the presence of atlantoaxial osteoartritis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Blood tests, MRI ad CT can be done to rule out other conditions such as arthritis, a fracture, spinal tumor, infections, tumors, ...

A CT scan also may be helpful in determining the extent of osteophyte formation and for planning of surgery. Verification of the origin of pain by intraarticular blocks is recommended.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Outcome Measures[edit | edit source]

Examination[edit | edit source]

The examination consist of a clinical and/or radiological diagnosis. The clinical symptoms are very typical: mostly unilateral occipitocervical pain aggravated by head rotation. The pain ascends unilaterally to the occiput, the parietal skull and in some cases even to the eye. The radiological diagnosis is primarily made on a standard atlas view, showing you the narrowing of the C1-C2 joint space. A bone scan showing increased uptake can also help to establish the diagnosis but is not mandatory. A CT scan can be performed to rule out a tumor or to assess the anatomical details of C1/C2 prior to screw fixation. Both clinical en radiological diagnosis has to be confirmed by intra-articular C1-C2 blocks.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (level of evidence 2B)

(See Category:Cervical Examination and Cervical examination for more information)

Medical Management[edit | edit source]

One of the medical interventions used for atlantoaxial osteoartritis are glucocorticoid injections. These injections are placed into the lateral atlantoaxial joints and has shown to be a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2B)
Furthermore the drug gabapentin may be useful in the symptomatic treatment of atlantoaxial osteoarthritis because of occipital neuralgia (greater or lesser). In the absence of subluxation or causes necessitating surgery, gabapentin may be a second-choice oral therapy before invasive procedures. Also high-dose nonsteroidal antiinflammatory drugs, muscle relaxants, tricyclic antidepressants, prednisone, and tapered or short-term narcotic agents have been suggested as oral medications. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2A)
A meta-analysis about posterior C1-C2 fusion indicates that posterior C1-2 fusion is a safe and effective solution for patients with lateral AAOA combined with neck pain. If conservative therapies fail to provide sufficient pain relief, modern fusion options offer low risk of morbidity and a high rate of arthrodesis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of evidence 2A)

Physical Therapy Management[edit | edit source]

The physical therapy for atlantoaxiale osteoarthritis includes a combination of different treatments such as neck support exercise programs, manipulation in combination with joint mobilization, low-power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy , intermittent traction and short waved therapy. But the management of symptomatic disease is still far from optimal Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. First and foremost, the patient should be encouraged to take a minimum of bedrest the first 48 hours after being diagnosed with acute osteoarthritisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. (level of evidence 2C)

Exercise programs[edit | edit source]

Neck support exercises are most efficient for mechanical neck disorders with or without headache. Manual therapies should be combined with exercise therapy for improving pain sensation and patient satisfaction Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. (Level of Evidence 1A)
The findings of a review by H Sarig-Bahat revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. (Level of Evidence 2A)

Neck pain is often caused by the upper trapezius muscle in which we speak of trapezius myalgia. Exercise programs can target the painful trapezius muscle with simple and inexpensive training equipment. These exercises are dynamic exercises with controlled movements: lifting and lowering the dumbbell should be done in about 3 seconds each repetition without sudden jerks or accelerations. The patient should use a weight that could be lifted for 8 repetitions (80% 1 RM). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(level of Evidence 2B)
The use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. No beneficial effects may be expected of stand-alone stretching exercises. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1A)

A good exercise consists of at least two sets of 3 repetitions (ie, a total of 6 repetitions) with rest periods of 2 minutes between sets to avoid muscle fatigue. For all exercises, the heaviest weight that can be lifted for an 8-repetition maximum (8-RM) are used. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (level of Evidence 2B)

The following exercises can be used to lower the tensioning of the upper trapezius: Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (level of Evidence 2B)

Shrugs(SHR):

Starting postion: Stand erect, hold the dumbbells to the side
Action: Elevate the shoulders while focusing on contracting the upper trapezius muscle.

One-arm rows(ONE):

Starting position: Bend torso forward to approximately 30 degrees from horizontal with one knee on the bench and the other foot on the floor.
Action: Maintain one arm in extension to support the body on the bench. Meanwhile pull the dumbbell toward the ipsilateral lower rib.

Upright rows (UPR):

Starting position: Stand erect and hold the dumbbells while the arms hang relaxed in front of the body.
Action: Lift the dumbbells toward the chest in a vertical line close to the body while the elbows are flexed and the shoulder abducted. (The elbows point out and upward.)

Reverse flys (REV):

Starting Position: Lay on your chest at a 45-degree angle from horizontal with the arms pointing toward the floor.
Action: Raise the dumbbells until the upper arms are horizontal, while the elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.

Lateral raises (LAT):

Starting position: Stand erect and hold the dumbbells to the side.
Action: Abduct the shoulder joints until the upper arms are horizontal. The elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.

Manual Therapy - Manipulations and mobilizations[edit | edit source]

There is strong evidence that demonstrates that manual therapy was not significantly superior to other interventions like exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy are significantly more satisfied with their care than patients who received any other single therapy. Furthermore there is a trend (in 3 studies) showing that the combination of manual therapy with exercise leads to larger improvements in pain, disability and patient-perceived recovery than manual therapy alone. The combination of manual therapy and exercise may be useful in treatment of mechanical neck disorders. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1A)

Mobilization and/or manipulation used in combination with exercise are beneficial for persistent mechanical neck disorders with or without headache. A significant difference was found in reduction in pain, improvement in function and global perceived effect. Mobilization and/or manipulation as a stand-alone treatment were not beneficial. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1A)

The case series by Yu H et al. suggests that symptoms of atlantoaxial osteoarthritis may be improved by upper cervical spinal manipulation combined with mobilization with a mechanical device called the S.M.A.R.T. adjuster This device consists of a lever-actuated mechanical jig and a pressure sensor so that it can detect tissue changes (temperature and density) thought to be a result of reduced spinal segmental motion. The device can transmit up to 20 lb/inch2 force impulse through a piezoelectric force sensor to mobilize joints. 10 patients were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. The frequency and intensity of cervical manipulations were set up on a case-by case basis, largely depending on patients’ tolerance to the manipulation. The age of the patient, cause, duration, and course of the arthritis were all taken into consideration. To patients whose symptoms were at the initial stage or who were in the early stage of recovery from injury, higher frequency and lower intensity were usually applied. When the symptoms of the osteoarthritis were under control a different frequency of care, such as once a week, was used. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 3A)

Spinal manipulation has been shown to mobilize the facet joints and increase facet joint space, which not only relieves the pain caused by joint degeneration but also restores joint mobility and lessens the degenerative process.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(Level of Evidence 1B)
It is very important to know that chiropractic manipulation can only be provided to patients who present no neurovascular deficits and no acute injuries. Subsequent to the upper cervical HVLA manipulation, patients receive supplementary mobilizations of the upper cervical region.

Low-power laser therapy[edit | edit source]

According to Ozdemir et al. low laser therapy can have a beneficial effect on pain and function. Pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed. All these items showed a significant improvement. However the article indicates that further research needs to be done to determine the exact beneficial mechanisms of Low-power Laser TherapyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. (level of evidence 1B)

Monteforte P. et al found a non significant pain improvement in a assessment after 20 days. Also a significant difference difference in the thickness of the subcutaneous soft tissue layer overlying the two superior trapezia was found. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 2B)

Pulsed electromagnetic fields.[edit | edit source]

During PEMF treatment, a pulsating electromagnetic field is produced. PEMF may promote the formation of collagen and human chondrocytes. In a study by Sutbeyaz ST et al., patients with cervical osteoarthritis lay on the mat for 30 min per session twice a day for 3 weeks. The whole body is administered by using a mat 1.8 x0.6 m in size. A mean intensity of 40 lT and a frequency range from 0.1 to 64 Hz was used. This therapy has a positive influence on pain levels, flexion and extension ranges and paravertebral muscle spasm Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.(Level of Evidence 1B)

The study by Trock et al. shows benefit from pulsed electromagnetic fields in painful osteoarthritis of the cervical spine. On the end of the treatment and one month later the experimental group has a better outcome in pain, pain on motion and tenderness than the placebo group. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1B)

Infra-red stimulation of local trigger points[edit | edit source]

Claims have been made that local heat is particularly useful in treating osteoarthritis pain. Infra-red stimulation causes a short term pain relief. Important to keep in mind is that the stimulation is applied on the areas of higher tension, the trigger points^{Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title}. (level of evidence 1B)

Massage[edit | edit source]

A review of Ezzo J et al. included 19 trails where massage as a stand-alone treatment or as a of a multimodal intervention have been examined. Because of inconclusive results of the trails, no recomandations for practise can be made. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1A)

The Cohrane review of Patel KC. et al included 15 trails. Because of the uncertain effectiveness of massage, no recommendations for practice could be made. Yet, massage for mechanical neck disorders as a stand-alone treatment was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (Level of Evidence 1A)

In further studies the massage treatment need to be characterized (frequency, duration, number of sessions, and massage technique). Also the long-term effects need to be assessed.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Short term results of physiotherapy[edit | edit source]

The study of Hey et al. showed significant results of physiotherapy as initial conservative therapy of degenerative spine diseases. Improvement are to be expected in the area of sleeping, reading/writing, working/doing homework and carrying heavy things. The therapeutic modalities are joint mobilization, dry hot pack, intermittent traction, short-wave therapy and interferential electrical stimulation^{Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title}. (level of evidence 1C)

Key Research[edit | edit source]

Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Bronfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders (Cochrane review) Cochrane Database of Systematic Reviews 2015;Issue 1

Resource[edit | edit source]

Clinical Bottom Line[edit | edit source]

Osteoarthritis of the atlantoaxial joints can be idiopathic degenerative and posttraumatic. The prevalence of the osteoarthritis increases with age and is not gender dependant. Only a minority of the patients become symptomatic. Radiological presence/signs of atlantoaxial osteoarthritis do not correlate with the severity of the patients symptoms if those are presented. Those symptomtic patients complain mostly about unilateral neck pain occuring with the slightest head rotation and a painful audible crepitation with head rotation. There is evidence that physical therapy including neck support exercise programs, manipulation in combination with joint mobilization, low power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy, intermittent traction and short waved therapy have a beneficial effect on the recovery. There is no current research exists that compares the most effective therapy. Current evidence notes that manual therapy was not significantly superior to other interventions as exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy reported being significantly more statisfied with their care than patients who received any other single therapy. Besides, they saw in three studies that there was a trend that manual therapy combined with excercise returned moderately larger improvements, although not statistically significant, in pain, disability and patient-perceived recovery than manual therapy alone. However, more research need to be done in this area that focuses on the most effective therapy treatments for this injury.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

Atlantoaxial Osteoarthritis: Difference between revisions

Revision as of 12:11, 4 June 2015

Contents

Search Strategy[edit | edit source]

Definition/Description[edit | edit source]

Clinically Relevant Anatomy[edit | edit source]

Epidemiology /Etiology[edit | edit source]

Characteristics/Clinical Presentation[edit | edit source]

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

Outcome Measures[edit | edit source]

Examination[edit | edit source]

Medical Management[edit | edit source]

Physical Therapy Management[edit | edit source]

Exercise programs[edit | edit source]

Manual Therapy - Manipulations and mobilizations[edit | edit source]

Low-power laser therapy[edit | edit source]

Pulsed electromagnetic fields.[edit | edit source]

Infra-red stimulation of local trigger points[edit | edit source]

Massage[edit | edit source]

Short term results of physiotherapy[edit | edit source]

Key Research[edit | edit source]

Resource[edit | edit source]

Clinical Bottom Line[edit | edit source]

Recent Related Research (from Pubmed)[edit | edit source]

References[edit | edit source]

Physiopedia

Content

Legal

@@ Line 1: / Line 1: @@
-A contribution by: De Cremer Wesli, Gonzalez Miguel, Pauwels Gertjan and Lippens Wout&nbsp;
+A contribution by: Biterys Thomas, Crauwels Nick, Dedoncker Axel, Muylle Teun, De Cremer Wesli, Gonzalez Miguel, Pauwels Gertjan and Lippens Wout&nbsp;
+<br>
 <div class="editorbox"> '''Original Editor ''' [[User:Wout Lippens|Wout Lippens]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}   </div>
 <br> <br>
+= Search Strategy  =
+Databases searched: Pubmed, PEDro, eMedicine, Medscape, Cochrane Database<br>Keywords searched: Atlantoaxial osteoarthritis, atlanto odentoid osteoarthritis, upper cervical osteoarthritis AND treatmant, physical therapy, physiotherapie<br>
 = Definition/Description  =
-Atlantoaxiale Osteoarthritis is a metabolically active, dynamic process that involves all joint tissues such as cartilage, synovium/capsule, ligaments and muscles. It refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life<ref name="1">Philip Conaghan et al. Osteoarthritis National clinical guideline for care and management in adults. Royal College of Physicians, 2008. (evidence level: 5)</ref><ref name="2">Serap Tomruk et al. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb;26(4):320-4. Epub 2005 Jun 29.</ref>. Atlantoaxiale osteoarthritis can be divided into idiopathic degenerative and posttraumatic osteoarthritis<ref name="3">Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (evidence level: 3A)</ref><ref name="4">Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (evidence level: 4)</ref> .
+Atlantoaxiale Osteoarthritis is a metabolically active, dynamic process that involves all joint tissues such as cartilage, synovium/capsule, ligaments and muscles. It refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life<ref name="1">Philip Conaghan et al. Osteoarthritis National clinical guideline for care and management in adults. Royal College of Physicians, 2008. (evidence level: 5)</ref><ref name="2">Serap Tomruk et al. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb;26(4):320-4. Epub 2005 Jun 29.</ref>.(Level of evidence 5, Level of evidence 1B) Atlantoaxiale osteoarthritis can be divided into idiopathic degenerative and posttraumatic osteoarthritis<ref name="3">Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (evidence level: 3A)</ref><ref name="4">Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (evidence level: 4)</ref> .(Level of evidence 3A, Level of evidence 4)
 <br>
-= 3 Epidemiology /Etiology  =
+= Clinically Relevant Anatomy  =
-Idiopathic osteoarthritis occurs in the elderly, where posttraumatic osteoarthritis occurs more often in the younger population. It has a prevelance between 4 and 8%<ref name="3" /><ref name="4" /> . Only a minority of patients become symptomatic. Most patients are female (74%) presenting with a unilateral osteoarthritis<ref name="4" />.
+The cervical spine consist of seven vertebrae. The first two vertebrae are the atlas (C1) and the axis (C2). They form a joint structure which is called atlantoaxial joint. This joint is responsible for 50% of all cervical rotation. Regarding anatomical structure and function, the two upper vertebrae differ from the five other [http://www.physio-pedia.com/Cervical_Vertebrae cervical vertebrae]. <ref name="18">18.	Schuenke M, Schulte E, Head and Neuroanatomy (THIEME Atlas of Anatomy), Thieme, 1 jan. 2011 - 414p. (Level of Evidence 5)</ref>(Level of evidence 5)
+The [http://www.physio-pedia.com/Atlas atlas] (C1) doesn't have a corpus and is ring-shaped. It has a thick arcus anterior, a thin arcus posterior, two prominent massae lateralis, and two processus transversi. On each massa lateralis are two facets: a superior facet (with the facies articularis superior) and inferior facet (with the facies articularis inferior). The concave, kidney-shaped superior articular facets (facing upward and inward) articulate with the downward and outward facing facets of the occipital condyles. <ref name="18">Schuenke M, Schulte E, Head and Neuroanatomy (THIEME Atlas of Anatomy), Thieme, 1 jan. 2011 - 414p. (Level of Evidence 5)</ref>
+The [http://www.physio-pedia.com/Axis axis]&nbsp;(C2) has a corpus vertebrae which contains the dens (odontoid process of the axis). This vertebra has five facies articularis: two superior, two inferior and one facies articularis anterior. The facies articularis anterior is found on the anterior aspect of the dens and articulate with the fovea dentis of the atlas. The facies articularis superior of the axis articulate with the facies articularis inferior of the atlas. The facies articularis inferior articulate with the facies articularis superior of the third cervical vertebrae (C3). <ref name="18">Schuenke M, Schulte E, Head and Neuroanatomy (THIEME Atlas of Anatomy), Thieme, 1 jan. 2011 - 414p. (Level of Evidence 5)</ref>
+The ligamenta alaria, apicis dentis, transversum atlantis provide stabilization and prevent posterior displacement of the dens in relation of the atlas. The ligamentum transversum atlantis holds the dens tight proximity to the posterior part of the anterior arch of the atlas. These ligaments still allow spinal collum rotation. Internal and external ligaments reinforce the craniocervical junction (atlanto-occipital joint), the lower atlanto-axial joint and other cervical segments. The surrounding postural muscles and the ligaments secure the spinal stability of the cervical spine and allow cervical motion.<ref name="18">Schuenke M, Schulte E, Head and Neuroanatomy (THIEME Atlas of Anatomy), Thieme, 1 jan. 2011 - 414p. (Level of Evidence 5)</ref>
+(See [http://www.physio-pedia.com/Atlanto-axial_joint Atlanto-axial joint] for more information.)&nbsp;
+= Epidemiology /Etiology  =
+Idiopathic osteoarthritis occurs in the elderly, where posttraumatic osteoarthritis occurs more often in the younger population. It has a prevelance between 4 and 8%<ref name="3" /><ref name="4" /> . Only a minority of patients become symptomatic. Most (symptomatic)patients are female (74%) presenting with a unilateral osteoarthritis,wich is typically triggered by rotation and can ascend to the occiput and towards frontal.<ref name="4">Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (Level of evidence level 4)</ref><ref name="25">A.Goel, A. Shah, Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: analysis of the management of 108 cases, journal of neurosurgery: spine, Jun 2010 / Vol. 12 / No. 6 / Pages 592-601 (level of evidence 3A)</ref>
+The prevalence of osteoarthritis of the atlanto-odentoid joint is higher when people get older. Liu et al. found that the rate of osteoarthritis was 16% in the age group 18-25 years, 23% in the age group 25-30 years, 33% in the age group 30-40 years, 54% in the age group 40-50 years, 70% in the age group 50-60 years, 87% in the age group 60-70 years, and 93% in the age group &gt;70 years. <ref name="19">Liu K, Lü Y, Cheng D, Guo L, Liu C, Song H, Chhabra A. The prevalence of osteoarthritis of the atlanto-odontoid joint in adults using multidetector computed tomography. Acta Radiol. 2014 Feb;55(1):95-100. doi: 10.1177/0284185113492722. Epub 2013 Jul 22. (Level of Evidence 2B)</ref><br>In addition, the severity of the osteoartritis increases with age.<ref name="19">Liu K, Lü Y, Cheng D, Guo L, Liu C, Song H, Chhabra A. The prevalence of osteoarthritis of the atlanto-odontoid joint in adults using multidetector computed tomography. Acta Radiol. 2014 Feb;55(1):95-100. doi: 10.1177/0284185113492722. Epub 2013 Jul 22. (Level of Evidence 2B)</ref><ref name="21">Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)</ref>&nbsp;Prescene or severity of ostearthritis of the atlanto-odentoid joint is not gender dependant.<ref name="19">Liu K, Lü Y, Cheng D, Guo L, Liu C, Song H, Chhabra A. The prevalence of osteoarthritis of the atlanto-odontoid joint in adults using multidetector computed tomography. Acta Radiol. 2014 Feb;55(1):95-100. doi: 10.1177/0284185113492722. Epub 2013 Jul 22. (Level of Evidence 2B)</ref><ref name="20">Lakshmanan P, Jones A, Howes J, Lyons K. CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis. Eur Spine J. 2005 Feb;14(1):78-83. Epub 2004 Jun 15. (Level of Evidence 2B)</ref>&nbsp;(Level of evidence 2B, Level of evidence 2B)
+The incidence of atlanto-odontoid degeneration is very high in patients who had an odontoid fracture but it's remarkable that the lateral atlantoaxial joints are relative spared.<ref name="20">Lakshmanan P, Jones A, Howes J, Lyons K. CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis. Eur Spine J. 2005 Feb;14(1):78-83. Epub 2004 Jun 15. (Level of Evidence 2B)</ref>Head loading is also a known cause of degeneration affecting the occipito-cervical region. <ref name="21">Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)</ref>&nbsp;(Level of evidence 2B)
+The severity of symptoms do not seem to correspond with the severity of the atlanto-axial osteoarthritis. In a study of Badve et al. there is no statistically significant association between presence of radiologic changes in male porters and their symptoms. <ref name="21">Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)</ref>&nbsp;According to Betsch MW et al. degeneration is associated with dens fractures, therefore cervical spine radiographs should be assessed for changes of atlantodens and atlanto-axial facet joints. <ref name="22">Betsch MW, Blizzard SR, Shinseki MS, Yoo JU. Prevalence of degenerative changes of the atlanto-axial joints. Spine J. 2015 Feb 1;15(2):275-80. doi: 10.1016/j.spinee.2014.09.011. Epub 2014 Sep 30. (Level of Evidence 2B)</ref><br><br><br>
+= Characteristics/Clinical Presentation  =
+Osteoarthritis of the atlantoaxial joints has been recognized as a distinct cause of occasionally severe&nbsp;occipitocervical pain in the elderly.<ref name="3">Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (level of evidence level 3A)</ref><ref name="4">Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (Level of evidence level 4)</ref> Degerative changes of atlantodens and atlanto-axial facet joints can contribute to pain and motion limitations. <ref name="22">Betsch MW, Blizzard SR, Shinseki MS, Yoo JU. Prevalence of degenerative changes of the atlanto-axial joints. Spine J. 2015 Feb 1;15(2):275-80. doi: 10.1016/j.spinee.2014.09.011. Epub 2014 Sep 30. (Level of Evidence 2B)</ref>&nbsp;Patients typically complain about unilateral neck pain occurring with the slightest head rotation. The pain ascends unilaterally to the occiput, the parietal skull and sometimes even to the eye. Patients also report visual problems often leading to an ophthalmologic work up. They also frequently report a painful audible crepitation with head rotation<ref name="3" /><ref name="4" /> . Pain reduces functional status by causing spasm in the surrounding muscles and by limiting the range of motion (ROM) of the neck, especially in the plane of axial rotation of C1-C2<ref name="2" /><ref name="3" /><br>
 <br>
-= 4 Characteristics/Clinical Presentation  =
+= Differential Diagnosis  =
+Common:<ref name="23">BMJ Publishing Group Limited 2015, Assessment of neck pain. BMJ Best Practice. Retrieved from http://bestpractice.bmj.com/best-practice/monograph/943/diagnosis/differential-diagnosis.html (Level of Evidence 5)</ref>
+*Cervical strain
+*[http://www.physio-pedia.com/Whiplash_Associated_Disorders Acute whiplash]<br><br>
+Uncommon: <ref name="23">BMJ Publishing Group Limited 2015, Assessment of neck pain. BMJ Best Practice. Retrieved from http://bestpractice.bmj.com/best-practice/monograph/943/diagnosis/differential-diagnosis.html (Level of Evidence 5)</ref>
+*[http://www.physio-pedia.com/Rheumatoid_Arthritis Rheumatoid arthritis]
+*[http://www.physio-pedia.com/Facet_Joint_Syndrome Cervical facet syndrome]
+*[http://www.physio-pedia.com/Adult-onset_Idiopathic_Torticollis Spasmodic torticollis]
+*Cervical fracture ([[Jefferson fracture|Jefferson fracture]], [http://www.physio-pedia.com/Odontoid_fractures Odontoid fractures], [http://www.physio-pedia.com/Hangman's_fracture Hangman's fracture])
+*Cervical dislocation
+*[http://www.physio-pedia.com/Cervical_Radiculopathy Cervical radiculopathy]
+*[http://www.physio-pedia.com/Cervical_Myelopathy Cervical Myelopathy]
+*Cancer: Metastatic or primary
+*[http://www.physio-pedia.com/Meningitis Meningitis]
+*[http://www.physio-pedia.com/Osteotomy Vertebral osteotomy]
+*Epidural abscess<br>
+Because of the rare prevalence, degenerative fibrosis of atlantoaxial osteoarthritis can be confused with other pathologic entities, such as rheumatoid fibrosis, tumors and migrated disc herniation.<ref name="3">Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (level of evidence level 3A)</ref>
-Osteoarthritis of the atlantoaxial joints has been recognized as a distinct cause of occasionally severe<br>occipitocervical pain in the elderly. Patients typically complain about unilateral neck pain occurring with the slightest head rotation. The pain ascends unilaterally to the occiput, the parietal skull and sometimes even to the eye. Patients also report visual problems often leading to an ophthalmologic work up. They also frequently report a painful audible crepitation with head rotation<ref name="3" /><ref name="4" /> . Pain reduces functional status by causing spasm in the surrounding muscles and by limiting the range of motion (ROM) of the neck, especially in the plane of axial rotation of C1-C2<ref name="2" /><ref name="3" />
+Also important is that atlantoaxial joint osteoarthritis should be considered in the differential diagnosis in elderly patients examined for neck pain with or without progressive quadriparesis.<br>The identification of a periodontoid ligamentous degenerative mass suggests the presence of instability of the atlantoaxial joint.<ref name="25">A.Goel, A. Shah, Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: analysis of the management of 108 cases, journal of neurosurgery: spine, Jun 2010 / Vol. 12 / No. 6 / Pages 592-601 (level of evidence 3A)</ref>&nbsp;<br>
 <br>
-= <sup></sup>5 Differential Diagnosis  =
+= Diagnostic Procedures  =
+Clinical evaluation should start with: <ref name="9">Todd AG. Cervical spine: degenerative conditions. Curr Rev Muscoskeletal Med. 2011. 4:168-174. (level of evidence 2C)</ref>
+*The medical history wich includes: the type, the start, the location and duration of symptoms, joint function, medical condition patient, medication, other treatments, family history, things that cause or aggravate pain, [http://www.physio-pedia.com/Red_Flags_in_Spinal_Conditions red flags]… <ref name="24">Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015 Feb;90(2):284-99. doi: 10.1016/j.mayocp.2014.09.008. (Level of Evidence 2A)</ref>
+*Physical examination includes: Range of motion tests, evaluation of spinal joints, nerve tests, reflexes, active examination, ...
+*Medical imaging and examination: X-rays can identify degeneration of joints, the presence of trauma, and bone related disorders. However, radiologic findings of osteaoarthritis do not corrolate to the severity of the osteoarthritis and associated symptomes. <ref name="21">Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)</ref>
+Radiology, autopsy, conventional computed tomography and multidetector computed tomography can be used to examine the presence of atlantoaxial osteoartritis.<ref name="21">Badve SA, Bhojraj S, Nene A, Raut A, Ramakanthan R. Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population. Spine (Phila Pa 1976). 2010 Feb 15;35(4):434-8. doi: 10.1097/BRS.0b013e3181b13320. (Level of evidence 2B)</ref>
+Blood tests, MRI ad CT can be done to rule out other conditions such as arthritis, a fracture, spinal tumor, infections, tumors, ...
+A CT scan also may be helpful in determining the extent of osteophyte formation and for planning of surgery. Verification of the origin of pain by intraarticular blocks is recommended.<ref name="4">Schaeren S, Jeanneret B. Atlantoaxial osteoarthritis: case series and review of the literature. Eur Spine J. 2005 Jun;14(5):501-6. (Level of evidence level 4)</ref><br>
-Because of their uncommon presentation, degenerative fibrosis of atlantoaxial osteoarthritis can be confused with other pathologic entities, including rheumatoid fibrosis, tumors, and migrated disc herniation.<ref name="3" />
+= Outcome Measures  =
-<br>
+*[http://www.physio-pedia.com/Neck_Disability_Index Neck Disability Index]
+*[http://www.physio-pedia.com/The_Bournemouth_Questionnaire Neck Bournemouth Questionnaire]
+*[http://www.physio-pedia.com/Neck_Pain_and_Disability_Scale Neck Pain and Disability Scale]
+*[http://www.physio-pedia.com/Numeric_Pain_Rating_Scale Numeric Pain Rating Scale]
+*[http://www.physio-pedia.com/Pain_Catastrophizing_Scale Pain Catastrophizing Scale]
+*[http://www.physio-pedia.com/Visual_Analogue_Scale Visual Analogue Scale]<br>
-= <sup></sup>6 Examination  =
+= Examination  =
-The examination consist of a clinical and/or radiological diagnosis. The clinical symptoms are very typical: mostly unilateral occipitocervical pain aggravated by head rotation. The pain ascends unilaterally to the occiput, the parietal skull and in some cases even to the eye. The radiological diagnosis is primarily made on a standard atlas view, showing you the narrowing of the C1-C2 joint space. A bone scan showing increased uptake can also help to establish the diagnosis but is not mandatory. A CT scan can be performed to rule out a tumor or to assess the anatomical details of C1/C2 prior to screw fixation. Both clinical en radiological diagnosis has to be confirmed by intra-articular C1-C2 blocks.<ref name="4" />
+The examination consist of a clinical and/or radiological diagnosis. The clinical symptoms are very typical: mostly unilateral occipitocervical pain aggravated by head rotation. The pain ascends unilaterally to the occiput, the parietal skull and in some cases even to the eye. The radiological diagnosis is primarily made on a standard atlas view, showing you the narrowing of the C1-C2 joint space. A bone scan showing increased uptake can also help to establish the diagnosis but is not mandatory. A CT scan can be performed to rule out a tumor or to assess the anatomical details of C1/C2 prior to screw fixation. Both clinical en radiological diagnosis has to be confirmed by intra-articular C1-C2 blocks.<ref name="4" />&nbsp;<ref name="32">Radiologic prevalence of advanced lateral C1-C2 osteoarthritis, Zapletal J1, de Valois JC. Spine (Phila Pa 1976). 1997 Nov 1;22(21):2511-3. (Level of Evidence 2B)</ref>&nbsp;(level of evidence 2B)
-<br>
+(See Category:[http://www.physio-pedia.com/Category:Cervical_Examination Cervical Examination] and [http://www.physio-pedia.com/Cervical_Examination Cervical examination] for more information)<br>
 <sup></sup>
-= 7 Medical Management (current best evidence)  =
+= Medical Management  =
+One of the medical interventions used for atlantoaxial osteoartritis are glucocorticoid injections. These injections are placed into the lateral atlantoaxial joints and has shown to be a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy. <ref name="15">Glémarec J, Guillot P, Laborie Y, Berthelot JM, Prost A, Maugars Y. Intraarticular glucocorticosteroid injection into the lateral atlantoaxial joint under fluoroscopic control. A retrospective comparative study in patients with mechanical and inflammatory disorders. Joint Bone Spine 2000 jan (Level of evidence 2B)</ref>&nbsp;(Level of evidence 2B)<br>Furthermore the drug gabapentin may be useful in the symptomatic treatment of atlantoaxial osteoarthritis because of occipital neuralgia (greater or lesser). In the absence of subluxation or causes necessitating surgery, gabapentin may be a second-choice oral therapy before invasive procedures. Also high-dose nonsteroidal antiinflammatory drugs, muscle relaxants, tricyclic antidepressants, prednisone, and tapered or short-term narcotic agents have been suggested as oral medications.&nbsp;<ref name="17">Ogoke BA et al. The management of the atlanto-occipital and atlanto-axial joint pain. Pain Physician. 2000. (Level of evidence 2A)</ref> (Level of evidence 2A)<br>A meta-analysis about posterior C1-C2 fusion indicates that posterior C1-2 fusion is a safe and effective solution for patients with lateral AAOA combined with neck pain. If conservative therapies fail to provide sufficient pain relief, modern fusion options offer low risk of morbidity and a high rate of arthrodesis.<ref name="16">Elliott RE, Tanweer O, Smith ML, Frempong-Boadu A. Outcomes of fusion for lateral atlantoaxial osteoarthritis: meta-analysis and review of literature. World Neurosurg. 2013 Dec (Level of evidence 2A)</ref>&nbsp;(Level of evidence 2A)<br><br>
-<br>
+= Physical Therapy Management  =
+The physical therapy for atlantoaxiale osteoarthritis includes a combination of different treatments such as neck support exercise programs, manipulation in combination with joint mobilization, low-power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy , intermittent traction and short waved therapy. But the management of symptomatic disease is still far from optimal <ref name="2" /><ref name="5">Hey HW, Lau PHD, Hee HT. Short-term results of physiotherapy in patients with newly diagnosed cervical spine disease. Singapore Med J 2012; 53(3): 179-182. (evidence level: 1C)</ref><ref name="6">Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994 Oct;21(10):1903-11. (evidence level: 1B)</ref><ref name="7">Ozdemir F, Birtane M, Kokino S. The clinical effect of low-power laser therapy on pain and function in cervical osteoarthritis. Clin Rheumatol. 2001;20(3):181-4. (evidence level: 1B)</ref><ref name="8">Lewith GT, Machin D. A randomized trial to evaluate the effect of infra-red stimulation of local trigger points, versus placebo, on the pain caused by cervical osteoarthrosis. Acupunct Electrother Res. 1981;6(4):277-84. (evidence level: 1B)</ref>. First and foremost, the patient should be encouraged to take a minimum of bedrest the first 48 hours after being diagnosed with acute osteoarthritis<ref name="11">Andrew G. Todd. Cervical spine: degenerative conditions. Curr Rev Muscoskeletal Med. 2011. 4:168-174. (evidence level: 2C)</ref>. (level of evidence 2C)<br>
+== Exercise programs  ==
+Neck support exercises are most efficient for mechanical neck disorders with or without headache. Manual therapies should be combined with exercise therapy for improving pain sensation and patient satisfaction&nbsp;<ref name="10">Gross A. et al. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002.Aug;7(3):131-49. (Level of evidence 1A)</ref>. (Level of Evidence 1A)<br>The findings of a review by H Sarig-Bahat revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders <ref name="11">H. Sarig-Bahat. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy Volume 8, Issue 1, February 2003, Pages 10–20 (level of Evidence 2A)</ref>. (Level of Evidence 2A)
+Neck pain is often caused by the upper trapezius muscle in which we speak of trapezius myalgia. Exercise programs can target the painful trapezius muscle with simple and inexpensive training equipment. These exercises are dynamic exercises with controlled movements: lifting and lowering the dumbbell should be done in about 3 seconds each repetition without sudden jerks or accelerations. The patient should use a weight that could be lifted for 8 repetitions (80% 1 RM). <ref name="12">Andersen Lars L et al. Muscle Activation During Selected Strength Exercises in Women With Chronic Neck Muscle Pain. Physical Therapy June 2008 vol. 88 no. 6 703-711. (Level of Evidence 2B)</ref>(level of Evidence 2B)<br>The use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. No beneficial effects may be expected of stand-alone stretching exercises. <ref name="27">Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Bronfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders (Cochrane review) Cochrane Database of Systematic Reviews 2015;Issue 1 (level of evidence 1A)</ref>&nbsp;(Level of Evidence 1A)
+A good exercise consists of at least two sets of 3 repetitions (ie, a total of 6 repetitions) with rest periods of 2 minutes between sets to avoid muscle fatigue. For all exercises, the heaviest weight that can be lifted for an 8-repetition maximum (8-RM) are used. <ref name="12">Andersen Lars L et al. Muscle Activation During Selected Strength Exercises in Women With Chronic Neck Muscle Pain. Physical Therapy June 2008 vol. 88 no. 6 703-711. (Level of Evidence 2B)</ref>&nbsp;(level of Evidence 2B)
+The following exercises can be used to lower the tensioning of the upper trapezius: <ref name="12">Andersen Lars L et al. Muscle Activation During Selected Strength Exercises in Women With Chronic Neck Muscle Pain. Physical Therapy June 2008 vol. 88 no. 6 703-711. (Level of Evidence 2B)</ref>&nbsp;(level of Evidence 2B)
+*Shrugs(SHR):
+#Starting postion: Stand erect, hold the dumbbells to the side
+#Action: Elevate the shoulders while focusing on contracting the upper trapezius muscle.
+*One-arm rows(ONE):
+#Starting position: Bend torso forward to approximately 30 degrees from horizontal with one knee on the bench and the other foot on the floor.
+#Action: Maintain one arm in extension to support the body on the bench. Meanwhile pull the dumbbell toward the ipsilateral lower rib.
-= 8 Physical Therapy Management (current best evidence)  =
+*Upright rows (UPR):
-The physical therapy for atlantoaxiale osteoarthritis includes a combination of different treatments such as neck support exercise programs, manipulation in combination with joint mobilization, low-power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy , intermittent traction and short waved therapy. But the management of symptomatic disease is still far from optimal <ref name="2" /><ref name="5">Hey HW, Lau PHD, Hee HT. Short-term results of physiotherapy in patients with newly diagnosed cervical spine disease. Singapore Med J 2012; 53(3): 179-182. (evidence level: 1C)</ref><ref name="6">Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994 Oct;21(10):1903-11. (evidence level: 1B)</ref><ref name="7">Ozdemir F, Birtane M, Kokino S. The clinical effect of low-power laser therapy on pain and function in cervical osteoarthritis. Clin Rheumatol. 2001;20(3):181-4. (evidence level: 1B)</ref><ref name="8">Lewith GT, Machin D. A randomized trial to evaluate the effect of infra-red stimulation of local trigger points, versus placebo, on the pain caused by cervical osteoarthrosis. Acupunct Electrother Res. 1981;6(4):277-84. (evidence level: 1B)</ref>. First and foremost, the patient should be encouraged to take a minimum of bedrest the first 48 hours after being diagnosed with acute osteoarthritis<ref name="11">Andrew G. Todd. Cervical spine: degenerative conditions. Curr Rev Muscoskeletal Med. 2011. 4:168-174. (evidence level: 2C)</ref>. <br>
+#Starting position: Stand erect and hold the dumbbells while the arms hang relaxed in front of the body.
+#Action: Lift the dumbbells toward the chest in a vertical line close to the body while the elbows are flexed and the shoulder abducted. (The elbows point out and upward.)
-== 8.1 Neck support exercise programs (evidence level: 2B)  ==
+*Reverse flys (REV):
-Neck support exercises should be the most beneficial for mechanical neck disorder with or without headache. Manual therapies should be done with exercise for improving pain and patient satisfaction<ref name="13">Gross A. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002.Aug;7(3):131-49.</ref>. Findings revealed relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck–shoulder musculature for chronic or frequent neck disorders<ref name="15">H. Sarig-Bahat. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy Volume 8, Issue 1, February 2003, Pages 10–20</ref>.
+#Starting Position: Lay on your chest at a 45-degree angle from horizontal with the arms pointing toward the floor.
+#Action: Raise the dumbbells until the upper arms are horizontal, while the elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.
-<br>Neck pain is often common from the upper trapezius muscle (trapezius myalgia). The aim of an exercise program is to target the painful trapezius muscle with simple and inexpensive training equipment. All exercises should be performed dynamically in a controlled manner: lifting (±1.5 seconds) and lowering (±1.5 seconds) the dumbbell without sudden jerks or accelerations. For all exercises the patient should better use a weight that could be lifted for an 8-repetition maximum (8-RM), which is determined 1 week before implementation.
+*Lateral raises (LAT):
-<br>A good exercise consists of at least two sets of 3 repetitions (ie, a total of 6 repetitions) with rest periods of 2 minutes between sets to avoid muscle fatigue.For all exercises, the heaviest weight that can be lifted for an 8-repetition maximum (8-RM) are used.
+#Starting position: Stand erect and hold the dumbbells to the side.
+#Action: Abduct the shoulder joints until the upper arms are horizontal. The elbows are in a static, slightly flexed position (∼5°) during the entire range of motion.<br>
 <br>
-Next you'll find a few exercises that can be used to lower the tensioning of the upper trapezius.<br>1. Shrugs: The subject stood erect and held the dumbbells to the side, and then elevated the shoulders while focusing on contracting the upper trapezius muscle.<br>2. One-arm rows: The subject bent her torso forward to approximately 30 degrees from horizontal with one knee on the bench and the other foot on the floor. The subject then pulled the dumbbell toward the ipsilateral lower rib, while the contralateral arm was maintained in extension and supported the body on the bench.<br>3. Upright rows: The subject stood erect and held the dumbbells while the arms hung relaxed in front of the body. The dumbbells were lifted toward the chest in a vertical line close to the body while the elbows were flexed and the shoulder abducted. The elbows pointed out and upward.<br>4. Reverse flys: The subject lay on her chest at a 45-degree angle from horizontal with the arms pointing toward the floor. The dumbbells were raised until the upper arms were horizontal, while the elbows were in a static, slightly flexed position (∼5°) during the entire range of motion .<br>5. Lateral raises: The subject stood erect and held the dumbbells to the side, and then abducted the shoulder joints until the upper arms were horizontal. The elbows were in a static, slightly flexed position (∼5°) during the entire range of motion<ref name="14">Andersen Lars L et al. Muscle Activation During Selected Strength Exercises in Women With Chronic Neck Muscle Pain. Physical Therapy June 2008 vol. 88 no. 6 703-711.</ref>.
+== Manual Therapy - Manipulations and mobilizations  ==
-<br>
+There is strong evidence that demonstrates that manual therapy was not significantly superior to other interventions like exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy are significantly more satisfied with their care than patients who received any other single therapy. Furthermore there is a trend (in 3 studies) showing that the combination of manual therapy with exercise leads to larger improvements in pain, disability and patient-perceived recovery than manual therapy alone. The combination of manual therapy and exercise may be useful in treatment of mechanical neck disorders. <ref name="28">Macaulay J, Cameron M, Vaughan B. The effectiveness of manual therapy for neck pain: a systematic review of the literature. Physical Therapy Reviews 2007 Sep;12(3):261-267</ref> (Level of Evidence 1A)
+Mobilization and/or manipulation used in combination with exercise are beneficial for persistent mechanical neck disorders with or without headache. A significant difference was found in reduction in pain, improvement in function and global perceived effect. Mobilization and/or manipulation as a stand-alone treatment were not beneficial. <ref name="31">Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, Cervical Overview Group. A Cochrane review of manipulation and mobilization for mechanical neck disorders [with consumer summary] Spine 2004 Jul 15;29(14):1541-1548 (Level of Evidence 1A)</ref>&nbsp;(Level of Evidence 1A)
-== 8.2 Manipulation combined with mobilization (evidence level: 1B)  ==
+The case series by Yu H et al. suggests that symptoms of atlantoaxial osteoarthritis may be improved by upper cervical spinal manipulation combined with mobilization with a mechanical device called the S.M.A.R.T. adjuster This device consists of a lever-actuated mechanical jig and a pressure sensor so that it can detect tissue changes (temperature and density) thought to be a result of reduced spinal segmental motion. The device can transmit up to 20 lb/inch2 force impulse through a piezoelectric force sensor to mobilize joints. 10 patients were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. The frequency and intensity of cervical manipulations were set up on a case-by case basis, largely depending on patients’ tolerance to the manipulation. The age of the patient, cause, duration, and course of the arthritis were all taken into consideration. To patients whose symptoms were at the initial stage or who were in the early stage of recovery from injury, higher frequency and lower intensity were usually applied. When the symptoms of the osteoarthritis were under control a different frequency of care, such as once a week, was used. <ref name="3">Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011 Feb;34(2):131-7. (level of evidence level 3A)</ref> (Level of Evidence 3A)
-The chiropractic manipulative technique consists of high velocity , low amplitude thrust to the upper cervical spine. The frequency and intensity of cervical manipulation should be delivered on a case-by case basis, largely depending on patients’ tolerance to the manipulation. The age of the patient, cause, duration, and course of the arthritis have to be taken into consideration. Spinal manipulation has been shown to mobilize the facet joints and increase facet joint space<sup><ref name="12">Cramer GD et al. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine (Phila Pa 1976). 2002 Nov 15;27(22):2459-66. (evidence level: 1B)</ref></sup>, which not only relieves the pain caused by joint degeneration but also restores joint mobility and lessens the degenerative process. It is very important to know that chiropractic manipulation can only provide to patients who present no neurovascular deficits and no acute injuries. Subsequent to the upper cervical HVLA manipulation, patients receive supplementary mobilizations of the upper cervical region.
+Spinal manipulation has been shown to mobilize the facet joints and increase facet joint space, which not only relieves the pain caused by joint degeneration but also restores joint mobility and lessens the degenerative process.<ref name="13">Cramer GD et al. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine (Phila Pa 1976). 2002 Nov 15;27(22):2459-66. (Level of evidence 1B)</ref>(Level of Evidence 1B)<br>It is very important to know that chiropractic manipulation can only be provided to patients who present no neurovascular deficits and no acute injuries. Subsequent to the upper cervical HVLA manipulation, patients receive supplementary mobilizations of the upper cervical region.<br><br>
-<br>
+== Low-power laser therapy  ==
-== 8.3 Low-power laser therapy (evidence level: 1B)  ==
+According to Ozdemir et al. low laser therapy can have a beneficial effect on pain and function. Pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed. All these items showed a significant improvement. However the article indicates that further research needs to be done to determine the exact beneficial mechanisms of Low-power Laser Therapy<ref name="7" /><ref name="9">F. Özdemir, M. Birtane and S. Kokino. The clinical efficacy of Low-Power laser therapy on pain and function in Cervical Osteoarthritis. Clinical Rheumatology. 2001. 20:181-184.. (evidence level: 1B)</ref>. (level of evidence 1B)
-According to Ozdemir et al. low laser therapy can have a beneficial effect on pain and function. Pain, paravertebral muscle spasm, lordosis angle, the range of neck motion and function were observed. All these items showed a significant improvement. However the article indicates that further research needs to be done to determine the exact beneficial mechanisms of Low-power Laser Therapy<ref name="7" /><ref name="9">F. Özdemir, M. Birtane and S. Kokino. The clinical efficacy of Low-Power laser therapy on pain and function in Cervical Osteoarthritis. Clinical Rheumatology. 2001. 20:181-184.. (evidence level: 1B)</ref>.
+<span style="font-size: 13.2799997329712px; line-height: 19.9200000762939px;">Monteforte P. et al found a non significant pain improvement in a assessment after 20 days. Also a significant difference difference in the thickness of the subcutaneous soft tissue layer overlying the two superior trapezia was found. <ref name="26">Monteforte P, Baratto L, Molfetta L, Rovetta G. Low-power laser in osteoarthritis of the cervical spine. Int J Tissue React. 2003;25(4):131-6. (level of Evidence 2B)</ref>&nbsp;(Level of Evidence 2B)</span><br>
-<br>
+== Pulsed electromagnetic fields.  ==
-== 8.4 Pulsed electromagnetic fields. (evidence level: 1B)  ==
+During PEMF treatment, a pulsating electromagnetic field is produced. PEMF may promote the formation of collagen and human chondrocytes. In a study by Sutbeyaz ST et al., patients with cervical osteoarthritis lay on the mat for 30 min per session twice a day for 3 weeks. The whole body is administered by using a mat 1.8 x0.6 m in size. A mean intensity of 40 lT and a frequency range from 0.1 to 64 Hz was used. This therapy has a positive influence on pain levels, flexion and extension ranges and paravertebral muscle spasm&nbsp;<ref name="2">Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb;26(4):320-4. Epub 2005 Jun 29. (Level of evidence 1B)</ref>.(Level of Evidence 1B)
-PEMF treatment is considered to promote the formation of collagen and human chondrocytes. During the treatment the patient lay on the mat for 30 min per session twice a day for 3 weeks. PEMF is administered to the whole body using a mat 1.8•0.6 m in size. The mat produced a pulsating electromagnetic field with a mean intensity of 40 lT (wave ranger professional, MRS 2000+Home, Eschestrasse 500, FL-9492 Eschen). The frequency of the PEMF ranges from 0.1 to 64 Hz. This therapy has a positive influence on pain levels, flexion and extension ranges and paravertebral muscle spasm<ref name="2" /><sup>.</sup>
+The study by Trock et al. shows benefit from pulsed electromagnetic fields in painful osteoarthritis of the cervical spine. On the end of the treatment and one month later the experimental group has a better outcome in pain, pain on motion and tenderness than the placebo group.&nbsp;<ref name="6">Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagnetic fields in the treatment of osteoarthritis of the knee and cervical spine. Report of randomized, double blind, placebo controlled trials. J Rheumatol. 1994 Oct;21(10):1903-11. (Level of evidence level 1B)</ref> (Level of Evidence 1B) <br><sup></sup>
 <sup></sup>
-== 8.5 Infra-red stimulation of local trigger points (evidence level: 1B)  ==
+== Infra-red stimulation of local trigger points  ==
-Claims have been made that local heat is particularly useful in treating osteoarthritis pain. Infra-red stimulation causes a short term pain relief. Important to keep in mind is that the stimulation is applied on the areas of higher tension, the trigger points<sup><ref name="8" /></sup>.
+<span style="line-height: 1.5em; font-size: 13.2799997329712px;">Claims have been made that local heat is particularly useful in treating osteoarthritis pain. Infra-red stimulation causes a short term pain relief. Important to keep in mind is that the stimulation is applied on the areas of higher tension, the trigger points</span><sup style="line-height: 1.5em;"><ref name="8" /></sup><span style="line-height: 1.5em; font-size: 13.2799997329712px;">. (level of evidence 1B)</span>
 <br>
-== 8.6 Short term results of physiotherapy (evidence level: 1C)  ==
+== Massage  ==
+A review of Ezzo J et al. included 19 trails where massage as a stand-alone treatment or as a of a multimodal intervention have been examined. Because of inconclusive results of the trails, no recomandations for practise can be made. <ref name="29">Ezzo J, Haraldsson BG, Gross AR, Myers CD, Morien A, Goldsmith CH, Bronfort G, Peloso PM. Massage for mechanical neck disorders: a systematic review [with consumer summary]. Spine 2007 Feb 1;32(3):353-362 (level of Evidence 1A)</ref>&nbsp;(Level of Evidence 1A)
+The Cohrane review of Patel KC. et al included 15 trails. Because of the uncertain effectiveness of massage, no recommendations for practice could be made. Yet, massage for mechanical neck disorders as a stand-alone treatment was found to provide an immediate or short-term effectiveness or both in pain and tenderness. <ref name="30">Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM. Massage for mechanical neck disorders (Cochrane review) [with consumer summary]. Cochrane Database of Systematic Reviews 2012;Issue 9 (Level of Evidence 1A)</ref> (Level of Evidence 1A)
+In further studies the massage treatment need to be characterized (frequency, duration, number of sessions, and massage technique). Also the long-term effects need to be assessed.<ref name="29">Ezzo J, Haraldsson BG, Gross AR, Myers CD, Morien A, Goldsmith CH, Bronfort G, Peloso PM. Massage for mechanical neck disorders: a systematic review [with consumer summary]. Spine 2007 Feb 1;32(3):353-362 (level of Evidence 1A)</ref> <ref name="30">Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM. Massage for mechanical neck disorders (Cochrane review) [with consumer summary]. Cochrane Database of Systematic Reviews 2012;Issue 9 (Level of Evidence 1A)</ref><br>
+== Short term results of physiotherapy  ==
-The study of Hey et al. showed significant results of physiotherapy as initial conservative therapy of degenerative spine diseases. Improvement are to be expected in the area of sleeping, reading/writing, working/doing homework and carrying heavy things. The therapeutic modalities are joint mobilization, dry hot pack, intermittent traction, short-wave therapy and interferential electrical stimulation<sup><ref name="5" /></sup>.
+The study of Hey et al. showed significant results of physiotherapy as initial conservative therapy of degenerative spine diseases. Improvement are to be expected in the area of sleeping, reading/writing, working/doing homework and carrying heavy things. The therapeutic modalities are joint mobilization, dry hot pack, intermittent traction, short-wave therapy and interferential electrical stimulation<sup><ref name="5" /></sup>. (level of evidence 1C)
 <br>
-= 9 Resource  =
+= Key Research  =
+Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Bronfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders (Cochrane review) Cochrane Database of Systematic Reviews 2015;Issue 1
-= <br>10 Clinical Bottom Line  =
+= Resource  =
-<br>
+= <br>Clinical Bottom Line  =
+Osteoarthritis of the atlantoaxial joints can be idiopathic degenerative and posttraumatic. The prevalence of the osteoarthritis increases with age and is not gender dependant. Only a minority of the patients become symptomatic. Radiological presence/signs of atlantoaxial osteoarthritis do not correlate with the severity of the patients symptoms if those are presented. Those symptomtic patients complain mostly about unilateral neck pain occuring with the slightest head rotation and a painful audible crepitation with head rotation. There is evidence that physical therapy including neck support exercise programs, manipulation in combination with joint mobilization, low power laser therapy, pulsed electromagnetic therapy, infra-red stimulation of local trigger points therapy, dry-hot pack therapy, intermittent traction and short waved therapy have a beneficial effect on the recovery. There is no current research exists that compares the most effective therapy. Current evidence notes that manual therapy was not significantly superior to other interventions as exercise, physical therapy, medication and short wave diathermy for relief of neck pain. However, patients who received manual therapy reported being significantly more statisfied with their care than patients who received any other single therapy. Besides, they saw in three studies that there was a trend that manual therapy combined with excercise returned moderately larger improvements, although not statistically significant, in pain, disability and patient-perceived recovery than manual therapy alone. However, more research need to be done in this area that focuses on the most effective therapy treatments for this injury. <br>
-== 11 Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
+= Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  =
 <div class="researchbox"> <rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1nSYta6vqy0mRmYMuNDuLS_gf6Z0bDLcdUHXbIsVqIrfdpyMJP|charset=UTF8|short|max=10</rss> </div>
 <br>
-= 12 References  =
+= References  =
 <references /><br>

Atlantoaxial Osteoarthritis: Difference between revisions

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