Cervical spine management in patients with rheumatoid arthritis. Review of the literature

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.     

Neck pain

Six conditions cause most of the neck pain complaints seen by primary care physicians: cervical muscle strain or sprain, torticollis, acceleration injury, myofascial pain dysfunction syndrome, and cervical osteoarthritis or rheumatoid arthritis. Most of them can be diagnosed and treated by the primary care physician. Of the more unusual causes, one should not miss a clinical fracture; a herniated cervical disc, spinal cord compression from a disc, or epidural tumor; infection of the disc or the vertebral body; subluxation of the vertebral bodies; or pain referred from the chest or mediastinal structures. MRI offers new opportunity for early diagnosis of myelopathy owing to OA or RA, vertebral osteomyelitis, and metastatic involvement of cervical vertebrae.     

Diagnosis and management of rheumatoid arthritis

Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis. Women, smokers, and those with a family history of the disease are most often affected. Criteria for diagnosis include having at least one joint with definite swelling that is not explained by another disease. The likelihood of a rheumatoid arthritis diagnosis increases with the number of small joints involved. In a patient with inflammatory arthritis, the presence of a rheumatoid factor or anti-citrullinated protein antibody, or elevated C-reactive protein level or erythrocyte sedimentation rate suggests a diagnosis of rheumatoid arthritis. Initial laboratory evaluation should also include complete blood count with differential and assessment of renal and hepatic function. Patients taking biologic agents should be tested for hepatitis B, hepatitis C, and tuberculosis. Earlier diagnosis of rheumatoid arthritis allows for earlier treatment with disease-modifying antirheumatic agents. Combinations of medications are often used to control the disease. Methotrexate is typically the first-line drug for rheumatoid arthritis. Biologic agents, such as tumor necrosis factor inhibitors, are generally considered second-line agents or can be added for dual therapy. The goals of treatment include minimization of joint pain and swelling, prevention of radiographic damage and visible deformity, and continuation of work and personal activities. Joint replacement is indicated for patients with severe joint damage whose symptoms are poorly controlled by medical management.     

Atraumatic joint and limb pain in the elderly

Patients who visit the emergency department often have complaints of joint and limb pain. The differential diagnosis, clinical presentation, and treatment choices can be vastly different in the young- or middle-aged population compared with the elderly population, and the concerns of each group must be addressed. The emergency physician is in a unique position in that they are frequently the first to see these individuals and have the opportunity to intervene before permanent disability ensues. Some of the more common etiologies of atraumatic joint and limb pain, including crystal deposition diseases such as gout and pseudogout, osteoarthritis, septic arthritis, and inflammatory arthritides such as rheumatoid arthritis will be addressed in this article. In addition,several arthritides specific to the elderly population such as poly-myalgia rheumatica and associated giant cell arteritis will be covered. Finally a discussion of cervical and lumbar disc disease, as well as gait disorders, and their impact on the elderly, will be presented.     

Rheumatoid arthritis: role of the nurse and multidisciplinary team

Rheumatoid arthritis is a complex chronic inflammatory condition which has both musculoskeletal and extra-articular effects. It is the most common inflammatory arthropathy, and has the potential to cause a significant impact on quality of life. The predominant features of the disease are inflammation, pain, reduced levels of function and increased morbidity. Despite the number of treatments available to suppress the effects of rheumatoid arthritis, it is not always possible to establish good control of the disease. It is imperative that the multidisciplinary team are involved with care to ensure that independence is maintained and function optimized. The role of the nurse in the management of rheumatoid arthritis is varied, ranging from providing specialist advice about how to manage the condition to caring for patients who are having joint replacements as a result of the increased levels of pain and damage it can cause.     

Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: a literature review

The aim of this study was to review the research literature on pain and quality of life (QoL) and the relationship between these variables among people aged 75 years and above with rheumatoid arthritis and/or osteoarthritis. A Medline and CINAHL search was carried out using MeSH terms rheumatoid arthritis, osteoarthritis, QoL and pain in various combinations. Seventeen articles were identified that met the requirements for methodological quality and inclusion criteria. No study focused only on respondents aged 75 years or over. The studies had varying representation of this age group. Pain was common in both groups and was found to increase with age and disease duration among those with rheumatoid arthritis but not among those with osteoarthritis. Increased pain could lead to depression. Pain, functional limitation and increased age were found to decrease QoL among those with rheumatoid arthritis and osteoarthritis alike. Social support was found to buffer against negative effects on QoL among those with osteoarthritis while no moderating effects were found in rheumatoid arthritis. Increased age was found to relate to pain (rheumatoid arthritis) and decrease QoL (both rheumatoid arthritis and osteoarthritis). It is, however, hard to draw any firm conclusions about older people's pain and QoL because of the lack of studies including respondents aged 75 years or over. Thus, research about pain and QoL, especially focusing on the old and the very elderly with rheumatoid arthritis/osteoarthritis, is needed. It also seems justified to say that nursing care should especially focus on older people and that these people should be assessed for their level of pain, functional limitations and QoL especially in the case of having rheumatoid arthritis and/or osteoarthritis.     

Anti-inflammatory agents for the treatment of musculoskeletal pain and arthritis

Pain produced by musculoskeletal disorders commonly misconceived as having mechanical etiology often is caused by inflammatory mechanisms. Simple analgesics (ie, those that lack anti-inflammatory action) often are used to treat musculoskeletal pain when an anti-inflammatory analgesic may be more effective for the painful condition. This review addresses the anti-inflammatory agents available for the symptomatic management of common inflammatory musculoskeletal conditions including osteoarthritis, rheumatoid arthritis, and low back pain.     

A large multicentre, parallel group, double-blind study comparing tenoxicam and piroxicam in the treatment of osteoarthritis and rheumatoid arthritis

A total of 1,328 patients with osteoarthritis or rheumatoid arthritis were entered into this double-blind, parallel group study of tenoxicam and piroxicam. The patient populations were well matched. An improvement was seen in pain on moving and at night in both groups and in both indications. Stiffness was also improved by both drugs, being most marked in the rheumatoid arthritis group. The primary efficacy variable was global assessment, and this showed tenoxicam to have slightly greater effect in osteoarthritis and the reverse in rheumatoid arthritis. There were no statistically significant differences in any of these findings. There were no significant differences in tolerance ratings, although the more serious gastrointestinal events occurred in the piroxicam group.     

The Effects of Self-Aromatherapy Massage on Pain and Sleep Quality in Patients with Rheumatoid Arthritis: A Randomized Controlled Trial

BackgroundRheumatoid arthritis is the most common form of inflammatory arthritis and can lead to pain, joint deformity, and disability, resulting in poor sleep quality and lower quality of life. The efficacy of aromatherapy massage on pain levels and sleep quality among rheumatoid arthritis patients remains unclear.AimsTo investigate the effects of aromatherapy on pain and sleep quality among rheumatoid arthritis patients.MethodsThis randomized controlled trial enrolled 102 patients with rheumatoid arthritis from one regional hospital in Taoyuan, Taiwan. Patients were randomly assigned to the intervention (n = 32), placebo (n = 36), or control groups (n = 34). The intervention and placebo groups underwent self-aromatherapy hand massage guided by a self-aromatherapy hand massage manual and video for 10 minutes 3 times a week for 3 weeks. The intervention group used 5% compound essential oils, the placebo group used sweet almond oil, and the control group had no intervention. Pain, sleep quality and sleepiness were measured by using the numerical rating scale for pain, the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale at baseline and at 1, 2, and 3 weeks after the intervention.ResultsThe intervention and placebo groups had significantly decreased sleep quality and sleepiness scores from baseline to 3 weeks after aromatherapy massage. Compared with the control group, the intervention group showed statistically significant improvement in the sleep quality scores in the first weeks after aromatherapy massage (B = -1.19, 95% confidence interval [CI]: -2.35, -0.02, P =.046), but no statistically significant differences were found in the changes in pain levels from baseline to the three time points.ConclusionsAromatherapy massage is effective in improving sleep quality in rheumatoid arthritis patients. More studies are needed to evaluate the effects of aromatherapy hand massage on the pain levels of rheumatoid arthritis patients.     

Role of interleukin-17 in cartilage and bone destruction in rheumatoid arthritis

Interleukin 17 is a newly discovered inflammatory cytokine produced by T cells. Although pathogenesis of rheumatoid arthritis is still unknown more and more data show that IL-17 has an influence in this process. The concentration of this interleukin is very high locally in the joint fluid and synovium of the patients with rheumatoid arthritis. The most recent studies show, that IL-17 is situated at the top of inflammatory cascade and stimulates fibroblasts, synovial cells and macrophages to higher production of proinflammatory cytokines. Moreover IL-17 initiates the loss of proteoglycans and stimulates increased production of enzymes in chondrocytes causing degradation of collagen. Rheumatoidal synovial fibroblasts produce metalloproteinases, which can be regulated by IL-17 in the presence of proinflammatory cytokines. It is suggested, that IL-17 stimulates osteoblasts to synthesis of prostaglandin E2 (PGE2) and expression of receptor gene NF - kappa ss (RANK), which induces osteclastogenesis. Probably IL-17 is responsible for intensive resorption of bone tissue in rheumatoid arthritis. It seems, that IL-17 plays an important role in the immunological response and in the destruction of cartilage and bone tissue in rheumatoid arthritis. The deeper understanding of the mechanism of IL-17 action on the cartilage and bone cells may help to introduce the new methods of treatment in rheumatoid arthritis.     

Age, pain, and coping with rheumatoid arthritis.

The purpose of this study was to examine the relationship of age and pain severity (i.e. mild versus severe pain) in predicting coping strategies of individuals with rheumatoid arthritis (RA). An age-stratified sample (N = 121) of individuals diagnosed with rheumatoid arthritis completed a modified version of the Coping Strategies Questionnaire (CSQ). Individuals were asked to report the coping strategies used for mild versus severe pain. Findings included: (1) older adults were more likely than younger adults to report use of maladaptive coping strategies in the context of mild, but not severe, RA pain, (2) older adults' reported patterns of coping reflected less-than-anticipated expertise in dealing with RA pain, and (3) individuals, regardless of age, reported use of more active coping strategies in the context of mild pain and use of more maladaptive coping strategies in the context of severe pain. The present study suggests that research regarding illness and coping is most informative when it captures the individual-situational interaction of dealing with stressors such as chronic pain.     

Synovial concentrations of the angiogenic peptides bFGF and VEGF do not discriminate rheumatoid arthritis from other forms of inflammatory arthritis

OBJECTIVES: To investigate whether concentrations of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) in aspirated synovial fluid can be used to distinguish rheumatoid arthritis from other forms of inflammatory arthritis. METHODS: bFGF and VEGF concentrations were measured in aspirated synovial fluid and serum samples from 66 patients with active arthritis (clinical diagnoses: rheumatoid arthritis (35 patients), psoriatic arthritis (9), reactive arthritis (11) and arthritis UNS (11)) utilizing commercial ELISA kits. RESULTS: In comparison with controls, elevated concentrations of VEGF were found in synovial fluid compared with in serum in all forms of arthritis. There were no significant differences in synovial fluid bFGF or VEGF concentrations between rheumatoid arthritis and the other forms of inflammatory arthritis. CONCLUSION: Both serum bFGF and VEGF concentrations were increased in patients with rheumatoid arthritis. Patients treated with steroids had lower synovial fluid bFGF concentrations. Synovial fluid levels of bFGF and VEGF were elevated but could not be used to distinguish rheumatoid arthritis from other forms of inflammatory arthritis.     

Surgically treated reactive arthritis of the ankle after COVID-19 infection: A case report

A 37-year-old man developed right ankle pain and swelling six days after being diagnosed with coronavirus disease (COVID-19). Despite conservative treatment, his ankle symptoms persisted. Magnetic resonance imaging and computed tomography showed synovial hypertrophy and bone erosion in the ankle. Following arthroscopic synovectomy, performed 69 days after the COVID-19 diagnosis, the pain improved significantly. The clinical course was consistent with that of reactive arthritis following severe acute respiratory syndrome coronavirus 2 infection. The pathological findings resembled rheumatoid nodules. The bone erosion may have originated from the inflammatory pathway, which resembles the mechanism of rheumatoid arthritis.     

Identification and isolation of a phospholipase A2 activating protein in human rheumatoid arthritis synovial fluid: induction of eicosanoid synthesis and an inflammatory response in joints injected in vivo

Eicosanoids are important mediators of the destructive arthropathy observed in rheumatoid arthritis. The rate-limiting step in the eicosanoid synthesis pathway is the availability of free arachidonic acid. The phospholipase enzymes release arachidonic acid from membrane phospholipids and thus play an important role in the regulation of eicosanoid production. We have previously demonstrated enhanced phospholipase A2 and C enzyme activities in cells from patients with rheumatoid arthritis and have also described a phospholipase A2 activating protein (PLAP) in mammalian cell lines. In an attempt to determine the biochemical basis of enhanced phospholipase A2 activity found in patients with inflammatory joint disease, we examined synovial fluid from patients with rheumatoid arthritis for PLAP. To determine whether PLAP was specific for rheumatoid disease, we assayed specimens from patients with other arthropathies. Histologic examination of rheumatoid joint tissue, with the use of immunohistochemical techniques, demonstrated high concentration of PLAP in monocytes, macrophages, chondrocytes, vascular smooth muscle, and endothelial cells. Human PLAP could be biochemically isolated from synovial fluid from patients with rheumatoid arthritis and was found to be similar to PLAP previously isolated from murine and bovine sources. To determine whether PLAP could directly mediate any aspect of inflammatory disease, purified PLAP was injected into rabbit knee joints. This resulted in an acute inflammatory arthritis with synovial cell proliferation and synovial fluid leukocytosis. Purified PLAP also induced eicosanoid formation both in vivo and in vitro. With enzyme-linked immunosorbent assays, we found more PLAP in synovial fluid specimens from patients with rheumatoid arthritis compared with samples from patients with other inflammatory arthropathies as well as osteoarthritis, a noninflammatory arthropathy. These data suggest that PLAP may be responsible, at least in part, for some aspects of the destructive inflammatory arthropathy that is observed in patients with rheumatoid arthritis.     

Rheumatic mimics and selected triggers of fibromyalgia

Fibromyalgia is a chronic pain syndrome of unknown etiology characterized by diffuse pain and tender points, which have been present for more than 3 months. Many patients with systemic illnesses can have diffuse pain similar to that found in fibromyalgia, including rheumatic diseases such as polymyalgia rheumatica, rheumatoid arthritis, idiopathic inflammatory myopathy, systemic lupus erythematosus, and joint hypermobility. Osteomalacia and thyroid disease are also in the differential diagnosis of diffuse pain and are imminently treatable. In addition, there has been interest throughout the past 10 years in infectious diseases including hepatitis C, Lyme disease, coxsackie B, HIV, and parvovirus infection, which may cause or trigger fibromyalgia. This paper provides a framework to use when identifying these diseases as part of the evaluation of a patient with chronic widespread musculoskeletal pain.     

Cervical pain in the athlete: common conditions and treatment

In summary, it is important for physicians dealing with neck pain in an athletic population to understand the differences between serious and mild cervical injuries. This is best facilitated by a thorough understanding of the signs and symptoms of serious cervical injury, familiarity with the basic anatomy of the neck and its structures, and a working knowledge of common causes of neck pain and mechanisms of injury. All unconscious athletes should be assumed to have a serious cervical injury until proven otherwise, and preventive measures should be taken to ensure the safety of the athlete. This includes airway management with a jaw thrust only, neck stabilization, and preventing helmet removal. In the conscious athlete who has neck pain, serious cervical injury can often be ruled out with an accurate history and physical examination.In all cases of neck pain, it is imperative that the athlete be protected.This may involve removing the athlete from competition, or transporting him or her to the local emergency room. Often, this decision falls on the shoulders of the doctor in the stands. Thus, a basic understanding of the evaluation and management of neck pain in athletes is an asset for all physicians who frequent athletic events or see athletes in the office.The physician responsible for patients who have Down syndrome or rheumatoid arthritis needs to consider the increased incidence of cervical instability in these patients when evaluating for athletic participation or neck pain.     

Imaging of low back pain in children and adolescents

In children with low back pain (LBP), a specific cause is often identified. LBP has a relatively high prevalence during school years. However, only a minority of the children suffering from LBP seek medical attention. Protracted back pain in childhood is a serious condition that should be thoroughly investigated. This article is a systematic review of the intrinsic causes of LBP. Imaging modalities are discussed, with emphasis on magnetic resonance imaging. We have divided the intrinsic causes of LBP into four main groups: mechanical, developmental, infectious/inflammatory, and neoplastic. Disk protrusion is prevalent in young athletes. Spondylolysis and spondylolisthesis are the most common causes of chronic LBP in children. Thoracic or thoracolumbar Scheuermann disease causes kyphosis while a lumbar localization is more painful. Childhood diskitis is associated with fever and leukocytosis. Spinal inflammatory arthritides in children include juvenile rheumatoid arthritis, the juvenile spondyloarthropathies, and SAPHO syndrome, where spine as well as sacroiliac joint changes may be seen. Cysts, tumors, tumor-like lesions, and metastases are infrequent causes of back pain in children. Several of these conditions are described and illustrated in this review of LBP in children and adolescents.     

Rheumatoid arthritis: refractory to infliximab, a tumor necrosis factor inhibitor

Rheumatoid arthritis is one of the commonest autoimmune diseases. It is a chronic, progressive, systemic inflammatory disorder affecting the synovial joints and typically producing symmetrical arthritis. If left untreated, it leads to joint destruction and thus deformity and disability.In the recent years, advances in molecular biology have led to a variety of new treatment approaches to rheumatoid arthritis and other systemic inflammatory diseases associated with autoimmunity. Anti tumor necrosis factor (TNF) agents are emerging in the frontline management of rheumatoid arthritis (RA) in the current era of biological treatment.?We presented a 46-year-old Chinese female with a history of seropositive RA for the past 22 years refractory and intolerant to multiple medications including sulphasalazine (SSZ), leflunomide, hydroxychloroquine (HCQ) and methotrexate (MTX), thus infliximab, a tumor necrosis factor (TNF) inhibitor was initiated. However, despite receiving 6 cycles of infliximab therapy, she still complained of persistent disabled multiple joint pain and swelling. This report will discuss about rheumatoid arthritis, which is refractory to infliximab (a TNF inhibitor) and its alternative. KEYWORDS: Rheumatoid arthritis; Biologics treatment; Tumor-necrosis factor inhibitor; Infliximab.     

Circulating and intra-articular immune complexes in patients with rheumatoid arthritis. Correlation of 125I-Clq binding activity with clinical and biological features of the disease.

The correlation between the incidence and level of immune complexes in serum and synovial fluid and the various clinical and biological manifestations of rheumatoid arthritis has been studied. Immune complexes were quantitated using a sensitive radioimmunoassay, the 125I-Clq binding test, in unheated native sera and synovial fluids from 50 patients with seropositive (RA +) and 45 with seronegative (RA -) rheumatoid arthritis, 17 with other inflammatory arthritis, and 37 with degenerative and post-traumatic joint disease. The following observations were made: (a) when compared to the results from patients with degenerative and post-traumatic joint diseases, the 125I-Clq binding activity (Clq-BA) in synovial fluid was found to be increased (by more than 2 SD) in most of the patients with RA + (80%) and RA - (71%) and in 29% of patients with other inflammatory arthritis; the serum Clq-BA was also frequently increased in both RA + (76%) and RA - (49%) patients, but only exceptionally in patients with other inflammatory arthritis (6%); (b) a significant negative correlation existed between the Clq-BA and the immunochemical C4 level in synovial fluids from patients with RA + and RA -; (c) neither the serum nor the synovial fluid Clq-BA in rheumatoid arthritis significantly correlated with the erythrocyte sedimentation rate, the clinical stage of the disease, or the IgM rheumatoid factor titer; and (d) the serum Clq-BA in patients with rheumatoid arthritis and extra-articular disease manifestations (40 +/- 34% in those with RA +,32 +/- 29% in those with RA -) was significantly increased as compared to the serum Clq-BA in patients with joint disease alone (24 +/- 30% in those with RA +, 10 +/- 13% in those with RA -). Experimental studies were carried out in order to characterize the Clq binding material in rheumatoid arthritis. This material had properties similar to immune complexes: it sedimented in a high molecular weight range on sucrose density gradients (10-30S) and lost the ability to bind Clq after reduction and alkylation, or after acid dissociation at pH 3.8, or after passage through an anti-IgG immunoabsorbant. DNase did not affect the Clq BA. These results support the hypothesis that circulating as well as intra-articular immune complexes may play an important role in some pathogenetic aspects of rheumatoid arthritis. The 125I-Clq binding test may also be of some practical clinical value in detecting patients who have a higher risk of developing vasculitis.     

Diagnostic value of the mean corpuscular volume in the detection of vitamin B12 deficiency

Objectives: To investigate whether concentrations of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) in aspirated synovial fluid can be used to distinguish rheumatoid arthritis from other forms of inflammatory arthritis. Methods: bFGF and VEGF concentrations were measured in aspirated synovial fluid and serum samples from 66 patients with active arthritis (clinical diagnoses: rheumatoid arthritis (35 patients), psoriatic arthritis (9), reactive arthritis (11) and arthritis UNS (11)) utilizing commercial ELISA kits. Results: In comparison with controls, elevated concentrations of VEGF were found in synovial fluid compared with in serum in all forms of arthritis. There were no significant differences in synovial fluid bFGF or VEGF concentrations between rheumatoid arthritis and the other forms of inflammatory arthritis. Conclusion: Both serum bFGF and VEGF concentrations were increased in patients with rheumatoid arthritis. Patients treated with steroids had lower synovial fluid bFGF concentrations. Synovial fluid levels of bFGF and VEGF were elevated but could not be used to distinguish rheumatoid arthritis from other forms of inflammatory arthritis.