Cervical Spine Management in Patients with
Rheumatoid Arthritis: Review of the Literature
Carolee Moncur and H James Williams
PHYS THER. 1988; 68:509-515.
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Cervical Spine Management in Patients with
Rheumatoid Arthritis
Review of the Literature
CAROLEE MONCUR
and H. JAMES WILLIAMS
Rheumatoid arthritis of the cervical spine is a well-recognized source of neck
pain. Discussion of the potential effects of various treatment interventions on the
tissues of patients with rheumatoid arthritis of the cervical spine, however, has
been scarce in the physical therapy literature. Physical therapists should understand the implications of this type of inflammatory arthritis when treating patients
with rheumatoid arthritis. The end-stage results of the inflammatory process and
the mechanical forces on the cervical spine can cause atlantoaxial subluxation,
atlantoaxial impaction, and subaxial subluxation. The purpose of this article is to
review the literature on several aspects of rheumatoid arthritis of the cervical
spine: 1) pathological anatomy, 2) clinical findings, 3) surgical management, 4)
management with cervical orthoses, and 5) physical therapy management.
Key Words: Arthritis, rheumatoid arthritis; Joint diseases.
Cervical spine involvement in patients with rheumatoid
arthritis (RA) is recognized as a significant source of neck
pain, with its effects ranging from minor restriction of range
of motion and pain to major neurological impairment and
even death. The joints of the cervical spine, like other joints
affected by RA, encounter synovitis; erosions; and weakening
and destruction of bone, cartilage, and ligamentous
structures.1
Cervical spine manifestations in patients with RA were first
described by Garrod in 1890, who concluded from his father's
clinical notebooks that 178 (28%) of 500 patients with RA
had arthritis in the cervical joints.2 Still described cervical
spine involvement in children with juvenile arthritis.3 The
presence of subluxation, especially of the occipitoatlantoaxial
complex, in inflammatory arthritides such as RA was described later.4,5 Various researchers have reported that up to
25% of patients with RA have subluxation at the atlantoaxial
articulations, and about 50% of patients with RA have subaxial subluxation at two or more vertebral levels.6,7 Smith et al
determined that 150 out of 962 inpatients with RA had
cervical subluxation at one or more vertebral levels.8
These findings have several clinical implications for physical therapists who treat patients with RA: 1) asymptomatic
patients may show radiographic evidence of cervical subluxation at some level, 2) patients with symptomatic complaints
may not have cervical subluxation, 3) patients' complaints of
pain in the cervical spine may occur in various patterns, 4)
patients may have variable neurological symptoms, and 5)
physical therapists should apply cervical spine therapeutic
techniques cautiously because of the fragile nature of the
tissues affected by RA.
C. Moncur, PhD, is Associate Professor, Division of Physical Therapy,
College of Health, University of Utah, 1140 Annex, Salt Lake City, UT 84112
(USA).
H. Williams, MD, is Professor, Division of Rheumatology, Department of
Internal Medicine, University of Utah.
This article was submitted December 29, 1986; was with the authors for
revision 19 weeks; and was accepted August 12, 1987. Potential Conflict of
Interest: 4.
We believe that a noticeable omission exists in the physical
therapy literature describing current thinking and physical
therapy management of the cervical spine in patients with
RA. The purpose of this review is to describe the pathological
anatomy, clinical findings, surgical and nonsurgical management, and physical therapy management of the cervical spine
in patients with RA.
PATHOLOGIC ANATOMY
The normal cervical spine has 14 serially arranged apophyseal (true synovial) joints between the skull and the first
thoracic vertebra. These joints, along with the odontoid-atlas
joints, the 10 joints of Luschka, and five fibrocartilaginous
intervertebral disks, comprise a total of 32 cervical joints that
are held in place by ligaments, muscles, and capsular structures.9,10(pp271-275) Rheumatoid arthritis is an inflammatory
arthritis that can result in ligamentous distention and rupture,
synovitis, articular cartilage destruction, and pannus formation. The effects of RA on bone are osteoporosis, cyst formation, and erosion. Postmortem dissections of cervical vertebrae have revealed synovial and granulomatous rheumatoid
lesions in the joints of Luschka, although no radiographic
evidence of cervical RA was present.9 The end-stage results of
the inflammatory process combined with the mechanical
forces on the cervical spine can injure the neck structures and
cause atlantoaxial subluxation, atlantoaxial impaction, and
subaxial subluxation. Atlantoaxial subluxation and dislocation at the C4-5 and C5-6 levels are among the most common
and serious complications of RA.11 Atlantooccipital dislocation has been described in the literature, but it is thought to
be of a very low incidence and is best identified by computerized axial tomography.12
Atlantoaxial Subluxation
Erosive disease in the atlantoaxial, atlantoodontoid, and
atlantooccipital joints and in the synovium-lined bursa be-
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509
tween the odontoid process and transverse ligaments provides
foci for potential atlantoaxial subluxation (Fig. 1). Complete
avulsion of the transverse ligaments, which maintain the
correct anatomical alignment of the odontoid process against
the anterior arch of the atlas, has been described and allows
the odontoid process to slip posteriorly and encroach upon
the spinal cord.11 Postmortem studies have shown that anterior subluxation exists in 11% to 46% of patients with atlantoaxial subluxation. Anterior subluxation is generally defined
as a forward or anterior slippage of the atlas with respect to
the axis that allows the odontoid process to move posteriorly
toward the spinal cord. A distance of 2 to 3 mm between the
posterior surface of the anterior arch of the atlas and the
anterior surface of the odontoid process is considered within
normal limits. When viewed on a lateral roentgenogram of
the patient's neck during forward flexion, a gap greater than
3 mm between the odontoid process and the atlas is considered to be anterior subluxation.13-15 A subluxation of greater
than 10 to 12 mm indicates a loss of integrity of the transverse,
alar, and apical ligaments.16 Subluxations of all types have
Fig. 1. Schematic depiction of the arthrology of the cervical spine (A) anterior view and (B) posterior view with the posterior elements of the
vertebrae removed. (Adapted from Williams and Warwick.10(pp447-449))
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been noted in 43% to 86% of patients with RA, but cervical
anterior subluxations have been reported in as few as 19%
and as many as 71% of patients with RA.7,9,17 Anterior
subluxation may be reduced by moving the patient's head
into extension, may remain unreducible, or may be uncorrectable within the normal degree of 2 to 3 mm.6,7,18-2°
Posterior subluxation, a backward dislocation of the atlas
onto the axis,21-27 occurs infrequently in patients with RA
and can cause spinal cord compression. Lateral subluxation
of the atlantoaxial joints and an accompanying rotational
deformity have been described in the literature and are difficult to assess radiographically.1 Lateral subluxation of the
atlantoaxial joints accounts for 21% of all atlantoaxial
subluxations26 and occurs when the atlas moves laterally with
respect to the axis. The articular facets of the atlantoaxial
joints may become eroded and unstable, precipitating lateral
motion of the vertebra. Lateral subluxation can be detected
on an anteroposterior view of a roentgenogram of the cervical
region taken through the open mouth of the patient.23
Atlantoaxial Impaction
Atlantoaxial impaction (ie, pseudobasilar invagination, cranial settling, or vertical subluxation) occurs when the skull
settles downward onto the atlas and the atlas settles onto the
axis. The impaction is caused by bony erosion and osteoporosis in the atlantooccipital and atlantoaxial joints. Atlantoaxial impaction occurs in 5% to 32% of patients with RA 1 7 , 1 9 , 2 8
and is measured commonly by establishing how far above
McGregor's line (a line drawn from the hard palate to the
occiput on a lateral view of a cervical spine roentgenogram)
the odontoid process has migrated (Fig. 2).26 Atlantoaxial
impaction is present when the odontoid process protrudes
above McGregor's line 8 mm in men and 9.7 mm in women.26
Subaxial Subluxations
Subaxial subluxations are found at multiple vertebral levels
and tend to be severe, giving a "stepladder" appearance to the
cervical spine on a roentgenogram.29-31 End-plate erosions
may be found in 12% to 15% of patients with RA and
subluxations in 10% to 20% of patients with RA.13,29,32 Narrowing and subluxation of C2-C3 or C3-C4 are characteristic
of patients with RA, although diskovertebral destruction does
not always accompany vertebral subluxation. The lack of
osteophyte formation is typical of RA. Subluxation may result
from disk destruction caused by synovitis with erosion of the
adjacent bone and disk13 or may be secondary to facet arthritis
and ligamentous laxity leading to chronic disk trauma with
destructive changes.18 The end result of encroachment on the
spinal cord may be pachymeningitis, arachnoiditis, and medullary compression.31
CLINICAL FINDINGS
Physical therapists who treat patients with RA should realize that the patient may be entirely asymptomatic in the
cervical spine but have radiographic evidence of cervical
subluxation at some vertebral level. The patient, however,
may have gnawing cervical neck pain related to a flare-up of
RA without subluxation of the joints.8 Confirmation of joint
and vertebral subluxation can only be made radiographically
or with tomography. Attention to and careful recording of
the patient's complaints and periodic methodical reevaluation
Fig. 2. Lateral view of the head and neck with McGregor's line
drawn from the hard palate to the occiput to measure atlantoaxial
impaction. (Adapted from Anderson JE: The head. In Anderson JE
(ed): Grant's Atlas of Anatomy, ed 8. Baltimore, MD, Williams &
Wilkins, 1983, p 7-1.)
of the patient's cervical spine will alert the therapist to contact
the patient's physician when concerns arise.
Various complaints regarding patterns of pain in the neck
have been reported in the literature. Generalized pain may
occur in the neck and occipital area,31 or the pain may radiate
from the occiput to behind the ears with aching and radiation
into the shoulders caused by head motion.8,17,33 Some patients
with RA may experience pain in the neck, occipital region,
or posterior scalp, or complain of headaches or a band-like
constriction of pain about the forehead. Pain may be aggravated by forward flexion of the head.34
Stiffness and crepitus, or a "clunking" sound, may be
apparent to the patient and the clinician as the patient moves
his head, particularly during rotation, which may be limited.33,34 As the patient moves his head into forward flexion,
a gibbous deformity of C2 may appear as the spinous process
protrudes posteriorly (Fig. 3).34 Radiating pain, numbness,
and tingling in the upper extremities and neck will be aggravated in some patients by forward flexion of the head. Some
patients prefer not to hyperextend their neck because that will
create symptoms. Patients often complain that their head feels
too heavy to hold up and that their neck muscles are weak.34
Neurological symptoms are also variable and are related to
the duration of RA. Specific neurological symptoms are flexor
spasms of the legs, absent abdominal reflexes, decreased position sense (not entirely attributable to the loss of the
mechanoreceptors of the joint), increased plantar flexor signs,
and other pyramidal tract signs. These neurological symptoms
usually appear in the later stages of RA. 3 1 , 3 4 , 3 5 Sensory phe-
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Fig. 3. Gibbous deformity of C2 (arrow) caused by subluxation of
the atlas on the axis in a patient with cervical rheumatoid arthritis.
nomena associated with RA may be numbness, paresthesia,
loss of sensation to hot and cold, transient hemianesthesia,33
or radicular symptoms in the upper extremities. Brown-Séquard syndrome may occur with atlantoaxial subluxation.35
Vertebrobasilar insufficiency may contribute to blackouts,
drop attacks, loss of equilibrium, tinnitus, vertigo, visual
disturbances, and diplopia.8,31,33-34 Bulbar disturbances may
appear during swallowing, phonation, and respiration. Bladder sphincter control may be lost, resulting in urinary retention or incontinence.
Death may result from spinal cord or medullary compression in patients with cervical RA, but such compression does
not appear to be the only cause of premature death in these
patients. Risk factors that appear to predispose patients with
cervical RA to spinal cord compression include being a male
patient, having an anterior atlantoaxial subluxation of greater
than 9 mm, and the presence of atlantoaxial impaction.26
SURGICAL MANAGEMENT
Subluxation of the atlantoaxial spine does not necessarily
indicate surgical intervention. Serious surgical consideration
should be given when the patient experiences intractable pain,
radicular pain, vertebrobasilar symptoms, or neurological deterioration. Severe subaxial subluxation or atlantoaxial impaction with impending neurological deficit, with or without
pain, may also be an indication for surgical stabilization.17,36
The greatest determinant of the need for surgical intervention is the patient's general condition. Patients who need
cervical stabilization often have crippling, debilitating disease.
Their airways are difficult to intubate because of neck instability. If the patients are longstanding steroid users, they may
have fragile, easily damaged skin; osteoporotic bone, susceptibility to infections; and wounds that heal poorly.
The results of atlantoaxial surgical fusions have generally
been disappointing. Posterior cervical fusions with or without decompression have usually been unsatisfactory and
accompanied by a high mortality rate.37,38 Patients undergo a
period of preoperative skeletal traction to reduce subluxations
and myelopathic changes.36-39 Some researchers suggest that
the fusion should extend distally to the site of pathological
subluxations in both atlantoaxial and subaxial joint
subluxations.36-39
Methyl methacrylate has been used successfully as an internal splint during arthrodesis of the cervical spine in patients
with RA.40,41 This treatment eliminates the encumbrance of
external fixation devices such as the halo cast. The chief
advantage of an internal splint is reduction of the skin complications that occur in surgery in the patient with chronic
RA. A composite of methyl methacrylate and metal wires is
advantageous when the occiput and inferior segments of the
cervical spine are arthrodesed, a pseudoarthrosis is repaired,
or multilevel fusion in osteoporotic bone is required.40
Transoral excision of the odontoid peg and soft tissues
pannus has been performed recently using computerized tomography to better define the abnormalities at the craniocervical junction in RA.12 A posterior occipitocervical fusion is
done in conjunction with the transoral excision, and the entire
operation is accomplished in one stage. The surgery does not
require preoperative skeletal traction to reduce the subluxation. Reported results of the combined surgical procedure are
encouraging, although follow-up of the 13 patients has been
short.42,43
MANAGEMENT WITH CERVICAL COLLARS
Cervical collars are commonly used to protect the necks of
patients with RA. In a prospective study of the progression of
RA in the cervical spine in 106 patients, researchers determined that diligent use of a supportive collar did not alter the
natural progression of RA. All of the patients in the study
who progressed to the severe neurological and radiographic
stages of RA did so while wearing a firm cervical collar.8,17
Cervical collar wearing was unacceptable to most patients,
although they complained of neck pain.
Cervical collars do not prevent RA progression, but they
are often prescribed with the rationale that a collar prevents
sudden neck flexion and extension that could result in neurological impairment or death. Johnson et al studied the
effectiveness of various cervical orthoses (a soft cervical collar,
Philadelphia collar, four-poster brace, cervicothoracic brace,
Somi brace, and halo device with a plastic body vest) in
limiting neck and head motion in healthy subjects.44 Fortyfour subjects (20-36 years of age) with normal cervical spines
participated in the study. Normal and unrestricted active
ROM inflexion,extension, lateral bending, and rotation were
measured roentgenographically and photographically and
compared to active ROM measured under the same conditions while wearing the cervical orthoses.
Subjects wearing the halo device with the plastic body vest
were assessed for flexion and extension between the occiput
and first thoracic vertebrae. The halo device with the plastic
body vest allowed only 4% of normalflexion-extensionof the
whole cervical spine. The cervicothoracic brace was the most
effective of the conventional orthoses, allowing 13% of normal
flexion-extension. This brace was followed in order of decreasing effectiveness by the four-poster brace (21%), the Somi
brace (28%), the Philadelphia collar (29%), and the soft
cervical collar (74%). The halo device with the plastic body
vest was most effective at controllingflexion-extensionof the
upper intervertebral joints (3.4° ± 0.8° of ROM at the atlan-
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toaxial joint; 2.4° ± 0.8° between C2 and C3). The cervicothoracic brace was most effective at the middle and lower
vertebral levels and better at controlling motion than the
other orthoses.
Rotation was poorly controlled by any conventional orthoses. The cervicothoracic brace, the most effective of the
conventional orthoses, allowed 18% of normal rotation. The
halo device, however, allowed 1 % of normal rotation and best
controlled lateral bending (4% of normal motion). All of the
conventional orthoses were ineffective in controlling lateral
motion when compared with the other motions. The researchers concluded that increasing the rigidity and length of the
cervical orthosis improved its ability to restrict motion in
healthy subjects.44
Althoff and Goldie investigated four commonly used cervical collars for management of atlantoaxial subluxation.45
Eleven patients with atlantoaxial subluxation participated in
the study and served as their own control. Each patient had
the following four collars tested on them: 1) soft cervical
collar, 2) Philadelphia collar, 3) Somi brace, and 4) fourposter collar. Lateral radiographs were taken with the patient
in flexion and extension before and after the application of
the various cervical collars. Angular measurements were calculated between flexion and extension ROMs. The distance
between the anterior arch of the atlas and anterior surface of
the odontoid process was also measured. Althoff and Goldie
concluded that the different cervical collars were unsatisfactory stabilizers of cervical motion (47%-81% of unrestricted
motion was allowed).45 None of the cervical collars stabilized
atlantoaxial instability. Firm collars with an occipital seat
tended to force the atlas to subluxate anteriorly when the
head was extended.
PHYSICAL THERAPY MANAGEMENT
Physical therapy is an important component of the total
management of patients with RA.46 Treatment is directed
toward 1) relieving pain and discomfort, 2) maintaining or
restoring ROM and muscle strength, and 3) helping patients
adapt activities of daily living that aggravate neck pain.
Relief of Pain and Discomfort
Before evaluating and treating the neck of the patient with
RA, the physical therapist should realize that cervical spine
RA is a potentially life-threatening condition. The main hazard of cervical spine subluxation is damage to the cervical
cord or vertebral artery. Death caused by spinal cord or brain
stem involvement may be misdiagnosed as a myocardial
infarction or cerebral accident. Spinal cord damage may be
responsible for more deaths in patients with RA than is
currently recognized.8 Physical therapists should make decisions about methods of pain relief for patients with RA with
knowledge of the potential hazards.
A wide variety of physical modalities have been advocated
for use in rheumatic diseases to decrease pain, relax musculature, and increase joint mobility. Any discussion of the use
of therapeutic modalities for arthritis management must not
discount the potential influence of the placebo phenomenon.
Because little is known about some of the actions of these
modalities in RA, the potential exists for unproven practices
to be perpetrated on patients. The efficacy of therapeutic
modalities on pain relief or on improvement of a functional
task must be determined with full awareness of the placebo
effect.47
Heat therapy has been widely advocated for patients with
RA. Superficial heat is used for pain relief, for relaxation, and
as a warming activity before muscle exercise. Although superficial heat is commonly used as a form of pain relief, few
controlled studies have described the actual changes in tissue
temperature and the comfort achieved through heat therapy.48-50 The anecdotal reporting of patients who have received even short-term pain relief from superficial heat should
not be discounted. Deep-heating treatments (ie, microwave
therapy, diathermy, or ultrasound) are generally contraindicated for direct use on inflamed, painful joints.50"53
Evaluation of the effectiveness of ice in the treatment of
RA is difficult, and few controlled cryotherapy studies have
been completed. Current thinking about the use of cryotherapy is based on early reports in the literature and anecdotal
histories.54 Patients' responses to the application of ice will
determine its continued use. The cold pack can be placed like
a collar around the patient's neck but should be removed if
the patient experiences excessive pain. The patient should be
observed closely for any adverse reactions to cryotherapy.
Physical therapists who fit patients with a soft foam collar
to protect their spine may believe that the soft, or light, plastic
collar provides relative stability, prevents excessive anterior
head flexion, relieves pain, and encourages ankylosis of the
unstable elements.9,17 Research does not show, however, that
soft collars give complete stability or encourage ankylosis of
the cervical spine in RA. The most that can be said about the
use of a soft cervical collar is that it may relieve pain during
day and night activities. Additionally, a soft collar has great
psychological value and gives patients a sense of stability and
protection and a sensation of neck warmth.
Intermittent cervical traction is not recommended because
of the potential of further damage to the integrity of the
cervical joints. Mobilization and manipulation techniques are
absolutely contraindicated.55,56 Physical therapists take considerable risks when attempting physical movement maneuvers of patients with cervical spine RA. Roentgenographs may
identify stable joints but will not give the entire status of the
transverse and alar ligaments and the facet joint soft tissues.
We believe that gentle stretching, ROM, and isometric exercises of the head and neck taught to the patient are preferable.
Transcutaneous electrical nerve stimulation has become a
popular modality for pain relief in RA. Mannheimer and
Carlsson determined that high-intensity TENS reduced joint
pain in 18 of 19 patients with RA.57 No reported studies have
examined the use of TENS on the cervical spine in RA, but
TENS has been shown to be an effective pain relief treatment
for other types of arthritides (low back disorders,58 osteoarthritis of the knee,59 Sudeck's atrophy, and reflex sympathetic
dystrophy60). The advantage of TENS is that patients can use
it at home after appropriate instruction by a physical therapist.
Maintaining or Restoring Range of Motion
and Muscular Strength
A frequent complaint of patients with cervical RA is the
feeling that their head is too heavy for their neck muscles to
hold up. Patients must be taught to accomplish gentle ROM
exercises of the head and neck and may need to be told to
avoid excessive hyperextension or any circumduction motions
of the head. Rather than do active hyperextension, the patients
can perform isometric extension against a pillow on their bed;
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against a wall; or in a high-backed, overstuffed chair. If
patients' hands are severely deformed, isometric contractions
of the neck against the hand may be impossible, and they
may use a beach ball placed between themselves and the wall
while sitting in a chair to perform isometric neck exercises.
Physical therapists should realize that cervical exercises may
aggravate rather than decrease RA pain. Patients with RA
should be reevaluated routinely to determine the extent of
neck aggravation caused by the exercise program.
Therapists should take precautionary measures when physically handling patients with RA. Not only must therapists be
judicious when the patient is unable to transfer, they must
also fulfill their role as an educator of the patient, family, and
staff about how patients should be transferred. Physical therapists should instruct patients not to use their head or neck
as a pivotal point when transferring from a bed, chair, or
automobile. Traumatic medullary compression can cause severe neurologic damage or even death. Nursing staff, orderlies,
and the patient's family members should learn appropriate
transfer methods that protect the patient's head and neck.
When assisting the patient out of bed, for example, the care
giver should not lift the patient from the back of the head,
but should roll the patient onto one side and bring him to a
sitting position by grasping him around the trunk under the
arms.
We do not intend to create anxiety in physical therapists
who are unfamiliar with RA and its manifestation in the
cervical spine. Physical therapists are unlikely to aggravate
the cervical spine seriously in patients with RA if they follow
proper handling techniques and precautions.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
CONCLUSIONS
30.
Rheumatoid arthritis of the cervical spine may cause atlantoaxial subluxation, atlantoaxial impaction, or subaxial subluxations. Some patients with RA, however, may experience
only neck pain resulting from the inflammatory process of
RA. Death may result from spinal cord or medullary compression. Physical therapists who treat patients with RA should
use wisdom and caution when designing and implementing a
treatment plan. Communication is imperative between all
members of the health care team, including patients and their
families.
31.
32.
33.
34.
35.
36.
37.
REFERENCES
38.
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Volume 68 / Number 4, April 1988
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515
Cervical Spine Management in Patients with
Rheumatoid Arthritis: Review of the Literature
Carolee Moncur and H James Williams
PHYS THER. 1988; 68:509-515.
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