Atlantoaxial Osteoarthritis

A contribution by: De Cremer Wesli, Gonzalez Miguel, Pauwels Gertjan and Lippens Wout 

Search Strategy

Pubmed – Pedro – Library VUB
Keywords: Osteoarthritis – Cervical osteoarthritis – Physical therapy – Revalidation cervical osteoarthritis – Clinical presentation – Etiology

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^1,2. Atlantoaxiale osteoarthritis can be divided into idiopathic degenerative and posttraumatic osteoarthritis ^3,4.

3 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% ^3,4. Only a minority of patients become symptomatic. Most patients are female (74%) presenting with a unilateral osteoarthritis⁴.

4 Characteristics/Clinical Presentation

Osteoarthritis of the atlantoaxial joints has been recognized as a distinct cause of occasionally severe
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 ^3,4. 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 ^2,3

5 Differential Diagnosis

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.³

6 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.⁴

8 Physical Therapy Management (current best evidence)

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 ^2,5,6,7,8. First and foremost, the patient should be encouraged to take a minimum of bedrest the first 48 hours after being diagnosed with acute osteoarthritis¹¹.

8.1 Neck support exercise programs (evidence level: 2B)

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 satisfaction¹³. 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 disorders¹⁵.

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.

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.

Next you'll find a few exercises that can be used to lower the tensioning of the upper trapezius.
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.
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.
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.
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 .
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 motion¹⁴.

8.2 Manipulation combined with mobilization (evidence level: 1B)

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 space¹², 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.

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^7,9.

8.4 Pulsed electromagnetic fields. (evidence level: 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^2.

8.5 Infra-red stimulation of local trigger points (evidence level: 1B)

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 points⁸.

8.6 Short term results of physiotherapy (evidence level: 1C)

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 stimulation⁵.

12 References

1. Philip Conaghan et al. Osteoarthritis National clinical guideline for care and management in adults. Royal College of Physicians, 2008. (evidence level: 5)
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.
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)
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)
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)
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)
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)
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)
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)
10. 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)
11. Andrew G. Todd. Cervical spine: degenerative conditions. Curr Rev Muscoskeletal Med. 2011. 4:168-174. (evidence level: 2C)
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)
13. Gross A. Manual therapy for mechanical neck disorders: a systematic review. Man Ther. 2002.Aug;7(3):131-49.
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.
15. H. Sarig-Bahat. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy Volume 8, Issue 1, February 2003, Pages 10–20