Marko H. Neva

High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery

Objective: To study the prevalence of cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery, and symptoms that might be associated with the disorders. Methods: 194 patients with rheumatoid arthritis were referred for orthopaedic surgery at Jyväskylä Central Hospital, 154 (79%) of whom volunteered for the present study including clinical examination, laboratory tests, radiographs of the cervical spine, hands, and feet, and self report questionnaires. Definition of anterior atlantoaxial subluxation (aAAS) was >3 mm and of subaxial subluxation (SAS) ⩾3 mm. Atlantoaxial impaction (AAI) was analysed following to the Sakaguchi-Kauppi method. Results: 67 patients (44%) had cervical spine subluxation or previous surgical fusion. The prevalence of aAAS, AAI, SAS, or previous fusion was 27 (18%), 24 (16%), 29 (19%), and 8 (5%), respectively; 69% of patients with cervical spine subluxations (those with fusions excluded) reported neck pain, compared with 65% of patients without subluxations (p = 0.71). The prevalence of occipital, temporal, retro-orbital, and radicular pain in upper extremities was similar in patients with or without cervical spine subluxations (54% v 43%; 17% v 31%; 25% v 24%; 47% v 48%, respectively). However, patients with subluxations were older, had longer disease duration, more active disease, poorer function according to the Health Assessment Questionnaire, and had more often erosive disease. Conclusions: Asymptomatic cervical spine subluxation is common in patients with rheumatoid arthritis waiting for orthopaedic surgery. Regardless of symptoms, the possibility of cervical spine subluxation in patients with severe rheumatoid arthritis should be considered in preoperative evaluation.

Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations

OBJECTIVE To compare the efficacy of combination therapy with disease-modifying antirheumatic drugs (DMARDs) versus single therapy with DMARDs in the prevention of early cervical spine changes in patients with rheumatoid arthritis (RA). METHODS One hundred ninety-five patients with recent-onset RA (mean disease duration 8 months) were randomly assigned to receive a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single DMARD with or without prednisolone. After 2 years of followup, cervical spine radiographs were taken of 176 of these patients (85 in the combination-therapy group and 91 in the single-therapy group). These radiographs were evaluated, and the findings were correlated with the therapy strategies as well as with peripheral joint destruction and clinical and laboratory variables describing the disease activity. RESULTS Anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI; i.e., vertical subluxation), and subaxial subluxation (SAS) were found in only 6 (3.4%), 2 (1.1%), and 5 (2.8%) of the patients, respectively. Interestingly, none of the patients in the combination-therapy group had aAAS or AAI. The incidences of aAAS and AAI in the single-therapy group were 6.6% and 2.2%, respectively. SAS was present in 2 patients (2.2%) in the single-therapy group and in 3 patients (3.5%) in the combination-therapy group. The difference in the incidence of aAAS between the treatment groups was statistically significant (P = 0.029). None of the patients with cervical spine changes achieved remission of RA during the study. CONCLUSION In the present study, the incidence of cervical spine subluxations in patients treated with single-drug therapy was in accord with findings of previous studies. However, none of the patients in the combination-therapy group had aAAS or AAI. These findings suggest that early, aggressive combination-DMARD therapy with sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone can prevent or retard the development of rheumatoid atlantoaxial disorders.

Rheumatoid Atlantoaxial Subluxation Can Be Prevented by Intensive Use of Traditional Disease Modifying Antirheumatic Drugs

Objective. To evaluate the 5-year incidence of cervical spine disorders in patients with early rheumatoid arthritis (RA) treated by 2 different disease modifying antirheumatic drug (DMARD) strategies. Methods. In a national, multicenter, prospective FIN-RACo-trial, a cohort of 199 patients with early, clinically active RA was randomly assigned to treatment with a combination of 3 DMARD and prednisolone (Combi group) or with a single DMARD (Single group) with or without prednisolone, aiming to induce remission. After 2 years, the DMARD therapy was unrestricted. Lateral view cervical spine radiographs during full flexion and extension were taken at the 5-year followup visits. The presence of anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI), and subaxial subluxation (SAS) was assessed in the 149 patients with radiographs available (80 Single and 69 Combi). Results. At the 5-year visits, aAAS, AAI, and SAS were found in 13 (9%), 6 (4%), and 9 (6%) patients, respectively. The corresponding Single/Combi group ratios were 11/2, 5/1, and 5/4. Of the baseline data, only poor physical function [Health Assessment Questionnaire (HAQ); p = 0.024] and Single treatment strategy (p = 0.019) were significantly associated with aAAS. Worse HAQ scores and Disease Activity Score 28 values were found in patients who developed aAAS during the 5-year followup. Conclusion. RA patients with sustained clinical disease activity and poor HAQ are at increased risk of developing aAAS. The development of aAAS during the first 5 years of RA was rare among the patients treated with a combination of DMARD for at least 2 years from the diagnosis. Intensive treatment with traditional DMARD prevents or retards the development of aAAS in patients with recentonset RA.

Headmaster collar restricts rheumatoid atlantoaxial subluxation.

STUDY DESIGN A radiographic study of the effect of a modern orthotic device in the treatment of rheumatoid atlantoaxial subluxation. OBJECTIVE To study the ability of a new open-type collar to restrict atlantoaxial subluxation. SUMMARY OF BACKGROUND DATA Atlantoaxial subluxation is common in rheumatoid arthritis, and thus, the development of conservative treatments is important. It has been shown that a custom-made stiff collar significantly restricts atlantoaxial subluxation in approximately half of patients with unstable atlantoaxial subluxation. METHODS In 30 successive patients with rheumatoid atlantoaxial subluxation, lateral view radiographs were taken in flexion, extension, and neutral positions without a collar and in flexion with the Headmaster collar. RESULTS The mean atlantoaxial distance during flexion was 7.1 +/- 1.8 mm and during extension was 1.0 +/- 1.0 mm, and the mean instability was 6.1 +/- 2.3 mm. In the 20 cases with the greatest stabilizing effect, the mean atlantoaxial distance during flexion with a collar was 1.1 +/- 1.3 mm, whereas in 10 patients with lesser effect it was 6.7 +/- 2.5 mm (P < 0.0001). The lesser stabilizing effect was associated with the presence of atlantoaxial subluxation in the neutral position. CONCLUSION The Headmaster collar is an effective and useful tool in the conservative treatment of simple unstable atlantoaxial subluxation, but an ordinary custom-made stiff collar is still often needed. These two collars are complementary, and their selection and use must be determined individually.

Disability and health-related quality of life in patients undergoing spinal fusion: a comparison with a general population sample

BackgroundThe aim of the present study was to compare one-year-follow-up data on disability and health-related quality of life (HRQoL) between spinal fusion patients and age- and sex-matched general population.MethodsThe data on fusion patients were collected prospectively using a spinal fusion data base in two Finnish hospitals. A general population sample matched for age, sex and residential area was drawn from the Finnish Population Register. All participants completed a questionnaire and the main outcome measures were the Oswestry Disability Index (ODI) and the Short Form-36 questionnaire (SF-36).ResultsAltogether 252 (69% females) fusion patients and 682 (67% females) population sample subjects participated in the study. In general population the mean ODI was 15 (SD 17) in females and 9 (SD 13) in males. The corresponding preoperative ODI values were 47 (SD16) and 40 (SD 15) and one year follow-up values 22 (SD 17) and 23 (SD 20). In both sexes the ODI decreased significantly after surgery but remained higher than in the general population, p < 0.001. The physical component summary score (PCS) of the SF-36 was lower in the patients than general population sample both preoperatively and at one-year follow-up (p < 0.001). The mental component summary score (MCS) was lower preoperatively (p < 0.001), but reached the general population level after one year in both men (p = 0.42) and women (p = 0.61).ConclusionsDisability and HRQoL improved significantly after spinal fusion surgery during a one- year follow-up. However, the patients did not reach the level of the general population in the ODI or in the physical component of HRQoL at that time, although in the mental component the difference disappeared.

The early changes in trunk muscle strength and disability following lumbar spine fusion

Purpose: To analyze trunk muscle function pre- and postoperatively in patients undergoing lumbar spine fusion. Associations between changes in trunk muscle strength and disability were also studied. Method: A total of 114 patients undergoing lumbar spine fusion participated in the study. The flexion and extension strength of the trunk was measured preoperatively and 3 months after surgery using a strain-gauge dynamometer. Disability and pain during the past week was evaluated with the Oswestry disability index (ODI) and visual analog scale (VAS), respectively. Results: Preoperative trunk extension and flexion strength levels were 319 N and 436 N in males, respectively, and 160 N and 214 N in females, respectively. In females 3 months postoperatively, the trunk extension strength increased by 39 N (p < 0.001) and flexion by 38N (p < 0.001), whereas it remained unchanged in males. The preoperative extension/flexion strength ratio was 0.79 in females and 0.76 in males. Three months postoperatively, the strength ratio decreased to 0.66 in males (p = 0.02). The mean ODI improved by 47% and back pain decreased by 65% (both p < 0.001). The changes in the ODI correlated with changes in trunk extension (r = −0.38) and flexion (r = −0.43) strength. Conclusions: Patients undergoing lumbar spine fusion had low trunk muscle strength and strength imbalance. Back fusion surgery leads to considerable relief of pain and disability, but patients still have low trunk extension and flexion strength levels 3 months postoperatively. Therefore, there is need for a proper progressive strength training protocols to normalize back function. Implications for Rehabilitation Disability and pain decreased considerably during early recovery after lumbar fusion surgery. The changes in trunk muscle function were small and imbalances between the function of trunk extensor and flexor muscles still existed 3 months postoperatively. Back pain during straining was only weakly associated with strength values, indicating that the reasons for the low strength values are probably related to more than just pain inhibition. The correlation between the changes in trunk muscle strength and the changes in the ODI indicate that increase of muscle strength may decrease disability of these patients.

Chronic back pain in patients with rheumatoid arthritis and in a control population: prevalence and disability—a 5-year follow-up

OBJECTIVES To determine the prevalence of chronic back pain and its changes over 5 years in patients with RA compared with community controls and to evaluate the influence of chronic back pain in functional capacity, general pain and global health. METHODS The prevalence of chronic back pain in 1076 patients with RA and in 1491 community controls was evaluated using a mailed questionnaire, which also queried the functional capacity on the HAQ, and general pain and global health on visual analogue scales. RESULTS Chronic back pain was more frequent in the general population than in patients with RA: 19% of patients with RA and 25% of controls reported chronic back pain (P < 0.001). After 5 years, 57% of these patients initally reporting pain and 58% of controls still reported chronic back pain. In community controls with and without chronic back pain, the median HAQ, general pain and global health were 0.13 vs 0.00, 28 vs 6 and 28 vs 11, respectively (P < 0.001). The figures were 0.88 vs 0.63 (P = 0.05), 42 vs 26 and 42 vs 30 (P < 0.001), respectively, in patients with RA. All analyses were adjusted for age and sex. CONCLUSION Chronic back pain does not occur more frequently in patients with RA than in the general population. Almost 60% of patients and controls who reported chronic back pain still reported it 5 years later. In patients with RA and in the control population, subjects with chronic back pain had worse functional capacity, general pain and global health.

Randomized controlled trial of postoperative exercise rehabilitation program after lumbar spine fusion: study protocol

BackgroundLumbar spine fusion (LSF) effectively decreases pain and disability in specific spinal disorders; however, the disability rate following surgery remains high. This, combined with the fact that in Western countries the number of LSF surgeries is increasing rapidly it is important to develop rehabilitation interventions that improve outcomes.Methods/designIn the present RCT-study we aim to assess the effectiveness of a combined back-specific and aerobic exercise intervention for patients after LSF surgery. One hundred patients will be randomly allocated to a 12-month exercise intervention arm or a usual care arm. The exercise intervention will start three months after surgery and consist of six individual guidance sessions with a physiotherapist and a home-based exercise program. The primary outcome measures are low back pain, lower extremity pain, disability and quality of life. Secondary outcomes are back function and kinesiophobia. Exercise adherence will also be evaluated. The outcome measurements will be assessed at baseline (3 months postoperatively), at the end of the exercise intervention period (15 months postoperatively), and after a 1-year follow-up.DiscussionThe present RCT will evaluate the effectiveness of a long-term rehabilitation program after LSF. To our knowledge this will be the first study to evaluate a combination of strength training, control of the neutral lumbar spine position and aerobic training principles in rehabilitation after LSF.Trial registrationClinicalTrials.gov Identifier NCT00834015

Neutral Spine Control Exercises in Rehabilitation After Lumbar Spine Fusion

Abstract Tarnanen, SP, Neva, MH, Häkkinen, K, Kankaanpää, M, Ylinen, J, Kraemer, WJ, Newton, RU, and Häkkinen, A. Neutral spine control exercises in rehabilitation after lumbar spine fusion. J Strength Cond Res 28(7): 2018–2025, 2014—Lumbar spine fusion (LSF) has been reported to change the biomechanics of the spine and therefore the rehabilitation after LSF is important. In this study, the effect of selected neutral spine control exercises on activation of trunk muscles after LSF was evaluated. Muscle activity was measured by surface electromyography of the rectus abdominis, external oblique, longissimus, and multifidus muscles during 6 exercises in 22 LSF patients (mean age = 59 years; age range = 25–84 years; 50% women). Muscle activity concurrent with trunk flexion and extension during maximal voluntary isometric contraction (MVIC) was used as a reference value. Pain during the effort was assessed with a visual analog scale (VAS). The highest activity in the rectus abdominis muscles was measured during bilateral shoulder extension (51% of MVIC), and in the external oblique, it occurred during unilateral shoulder horizontal adduction (48% of MVIC) and unilateral hip extension (46% of MVIC) exercises. The highest activation of the multifidus and longissimus muscles (60–104%) was measured during bilateral shoulder flexion and modified Roman chair exercises. The mean (SD) self-reported back pain VAS scores during exercises varied from 3 (7) to 16 (26). Neutral spine control exercises activate trunk muscles and cause minimal pain and are therefore feasible exercises for home-based training to improve muscle endurance and postural control after LSF. In addition, the level of muscle activity during bilateral shoulder flexion and modified Roman chair exercises was over 60% of MVIC, justifying their use in training for strength of the trunk extensor muscles.

Decreased disability is associated with improved perceived quality of life following spinal fusion.

Purpose: To assess the disability and relationship between functional status and health related quality of life (HRQoL) in patients in the early recovery phase following spinal fusion. Methods: This is a prospective cohort study. Since 2008 data of spinal fusion patients have been collected prospectively in two Finnish hospitals. In August 2009, complete data of 173 patients were available. The measurement tool of disability was the Oswestry Disability Index (ODI) and it was also examined in the framework of International Classification of Functioning, Disability and Health (ICF) using body functions and structures, activities and participation components. Results: Preoperatively the mean total ODI was 45 (SD17) and mean (95% confidence interval) change to 3 months postoperatively was −19 (−22 to −17). When the ODI was linked to the ICF, there was a 55% improvement in the body structure and functions component and a 44% improvement in both the activities and the participation components. However, 25% of the patients still had the total ODI score over 40 three months postoperatively. Preoperatively, the mean (95% CI) Physical Component Summary Score (PCS) of the Short Form 36-questionnaire (SF-36) was 27 (26 to 28) and the mean Mental Component Summary Score (MCS) of SF-36 was 47 (45 to 49). Postoperatively the improvement was 9 (95% CI: 8 to 11) in PCS and 6 (95% CI: 4 to 7) in MCS (p < 0.001). Conclusions: Spinal fusion is successful in the early recovery period in terms of reduction of pain and disability. The significant changes in the ODI were seen in all three components of the ICF model. In addition, improvement in functioning was significantly related to positive change in HRQoL. Still there is a subgroup of patients having marked disability needing more intensive rehabilitation and follow-ups. Implications for Rehabilitation Spinal fusion The focus in assessing the outcome of spinal fusion operations has shifted towards patient-based health status and quality of life scales in recent years. When the patient’s self-rated Oswestry Disability Index (ODI) was examined in the framework of International Classification of Functioning, Disability and Health (ICF) it was competent to distinguish different domains of functioning from each other. However, the ODI does not cover earlier published comprehensive core set for low back pain completely and thus more comprehensive assessment is needed in clinical settings. This study showed that in the early recovery phase 3 months after the spinal fusion operation the positive changes in disability, health related quality of life and pain were significant. However, 25% of the patients still had the ODI score 40 or more at 3 months after the spinal fusion and these patients should be identified to be given additional attention to provide appropriate rehabilitation.