852: C spine RA and Muscle Pathology

CPG classification for C spine RA

• neck pain with mobility deficits

• Neck pain with movement coordination impairments

Pathobiological mechanism of RA

• progressive systemic autoimmune inflammatory condition that impacts primarily the smaller joints of the body

• Chronic inflammation leads to joint deformity and destruction due to loss of cartilage and bone erosions

  • Presence of inflammatory markers contributes to osteoclast production resulting in bony erosions and cartilage damage due to activation of chondrocytes

Risk factors for RA

Approximately 40% of those with this will develop a functional disability that impedes daily activities or ability to work within 10 years of diagnosis

Complications and comordibities associated with RA progression and treatment

• sjogren syndrome

• Coronary artery disease

• Pleuritis, interstitial lung disease

• Lymphoma

• Premature death

• Serious infections

• Osteopenia or osteoporosis

• Venous thromboembolic disease

• Depression

Symptoms of C spine RA

• subjective reports of instability

• Neuro deficits producing symptoms of myelopathy

• Neck pain

• Stiffness in c spine, but also extremities

• Swelling, deformities in distal joints

  • Typically small joints

  • Likely to note redness, warmth with swelling

• Painful and limited c spine ROM

• Muscle fatigue/soreness

Aggs for C spine RA

No specific aggs but likely related to limitations from exacerbation

Easing factors for C spine RA

No specific easing factors

24 hr pattern for C spine RA

• typically waxing and waning

• May have stiffness in the morning, likely taking >60 mins to ease

Objective examination for C spine RA

• may have + UCI special tests

  • More common with this condition

  • Sharp-pusher, transverse ligament

  • Alar ligament tests

• Neuro deficits if nerve roots are impacted by degenerative changes

• Stiffness in c spine but also distal extremities

• Swelling, deformities in distal joints

• Painful and limited c spine ROM in all planes

Potential pertinent history

• family history of RA

• Insidious onset of symptoms BL in arms, legs, and spine

Potential predisposing factors for C spine RA

• female sex

• Age: onset typically between 40-60

• Smoking

• Obesity

• Significant genetic component

  • 3x higher for first degree relative

PT management for C spine RA

• key is to be conservative with management, as aggressive therapy can generate an exacerbation or relapse

• Irritability of symptoms is very important here

• Manual therapy

  • Will depend if cervical instability present

  • Joint mobs, soft tissue mobs

  • Be cautious with with passive cervical mobility!

• Ther ex

  • C spine, thoracic, shoulder mobility, and strengthening exercises

  • Special focus on cervical stabilization/motor control activities

Reminders about exercise and pain

• sensitivity to noxious stimuli is shown to decrease after exercise

• In healthy populations, exercise induced analgesia occurs after

  • Aerobic exercise at 60-75% VO2max or isos for long duration at 25-50% max volitional contraction

• Exercise utilizes endogenous opioid and serotonin systems

  • Reduces central excitability and activates central inhibition

• Exercise alters peripheral and central immune function

  • Peripheral: release of anti inflammatory cytokines

  • Central: changes to glial cell activation

General strengthening guidelines

• isos are great for acute and/or moderate or severe neck pain

• Likely both cervical extensors and deep neck flexors will need strengthening

• Scapulothoracic musculature also is key for supporting the cervical spine and posture

• Shoulder girdle strengthening to further support scapulothoracic and cervical function

Medical management for C spine RA

• pharm: NSAIDs, corticosteroids, disease modifying anti-rheumatic drugs

• Surgery: gallie fusion, fusion of occipital and C2, posterior fusion

• Imaging: MRI

Pts with suspicion of RA that have not already been diagnosed should be referred to a rheumatologist for blood work including:

• rheumatoid factor

• C-reactive protein

• Sedimentation rate

• And others