Upper Cervical Manipulation Combined with Mobilization for the Treatment of Atlantoaxial Osteoarthritis: A Report of 10 Cases

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    ong Yu, MD,a Shuxun Hou, MD,b Wenwen Wu, MD,b



    ntoaxial osteoarthritis occurs in the


    ativetreatment consists of nonsteroidal anti-inflammatory drugs,

    Palmer College of Chiropractic Florida, 4777 City Center Parkway,


    A retrospective case review of 10 patients (5 men,

    Port Orange, FL 32129 (e-mail: shawn.he@palmer.edu)Paper submitted January 22, 2010; in revised form June 9, 2010.0161-4754/$36.00elderly; however, posttraumatic atlantoaxial osteoarthritis soft collar, and gentle traction, which can reduce pain to atolerable level. Steroid injections into the arthritic joint maybe successful for a limited period.8 No reports ofchiropractic manipulative therapy for the management ofatlantoaxial osteoarthritis were found. The purpose of thiscase series was to report the results of upper cervicalmanipulation combined with auxiliary spine instrumentadjuster therapy used as a conservative treatment of bothdegenerative and posttraumatic atlantoaxial osteoarthritis.

    a Attending Physician, Department of Orthopedics, The 1stAffiliatedHospital of the GeneralMilitaryHospital, Beijing, China.

    b Professor and Chief Physician, Department of Orthopedics,The 1st Affiliated Hospital of the General Military Hospital,Beijing, China.

    c Professor, Palmer College of Chiropractic Florida, PortOrange, Fla.Submit requests for reprints to: Xiaohua He,MD,MS, Professor,Copyright 20doi:10.1016/j.jmbetween the atlas and axis.1,2 It has aen 4% and 18%.2,3 Commonly, idiopathic

    the most common approach,4,5 and only a few casesreported that were treated with surgery.6,7 Conservprevalence betwe

    degenerative atlacause of severe neck pain and reduction of range ofotion (ROM)

    the treatment of this pathology. Conservative treatment wasweremechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatmentperiod. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physicalexamination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to amean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment wasimproved from 28 (3.1) to 52 (4.5). Restoration of joint space was observed in 6 patients. Overall clinicalimprovement was described as good or excellent in about 80% of patients. Clinical improvements in pain andrange of motion were seen in 80% and 90% of patients, respectively.Conclusion: Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.(J Manipulative Physiol Ther 2011;34:131-137)Key Indexing Terms: Atlantoaxial Joint; Osteoarthritis; Intractable Pain; Manipulation; Chiropractic

    tlantoaxial osteoarthritis is an uncommon clinicalcondition that has been recognized as a distinct

    occurs more often in younger patients. A search ofliterature revealed only a few reports on the diagnosisservices. All 10 patients selected for this series were treated with a combination of upper cervical manipulation andposttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographicpresentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedicABSTRACT

    Objective: This study presents the outcomes of patienosteoarthritis who were treated with upper cervical maClinical Features: A retrospective case review of 10C

    UMOH11 by National University of Health Sciences.pt.2010.12.005N COMBINED WITHMENT OF ATLANTOAXIALF 10 CASESand Xiaohua He, MD, MSc

    with idiopathic degenerative and posttraumatic atlantoaxialulation in combination with mobilization device therapy.atients who were diagnosed with either degenerative or5 women) with neck pain and atlantoaxial osteoarthritiswho were managed at our institution for the previous 5


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    132 Journal of Manipulative and Physiological TherapeuticsYu et alFebruary 2011Atlantoaxial Osteoarthritis and Upper Cervical ManipulationTable 1. Demographic information, pretreatment conditions, and


    Sex, age(y) atmanipulation

    Duration ofsymptomsbeforemanipulation(yr + mo)

    History ofneck injurybeforemanipulation



    1 M, 37 0 + 1 + L latC1-CL lat

    2 F, 70 0 + 2 R latC1-CR latosteo

    3 M, 46 0 + 2 + L latC1-CL lat

    4 M, 67 1 + 6 L latyears with the upper cervical manipulation combined withan auxiliary spine adjuster was conducted. The average ageof the patients was 50 years (range, 32-70 years). Sixpatients had a history of head or neck injuries. The averageage of these patients was below 50 years. Four patients hadno noticeable trauma, although radiographic evidence ofatlantoaxial osteoarthritis was presented. The chief com-plaint of these patients was unilateral neck pain occurringwith the slightest head rotation to the side of the lesion. TheROM between C1 and C2 was limited, especially in theplane of axial rotation. The physical examination usuallyrevealed tenderness at the C2 level. Neurologic status wasalso evaluated to exclude any signs of neurologicpathology. The diagnosis of atlantoaxial osteoarthritiswas confirmed by plain radiographs (anterior/posterior,open mouth, and lateral views) taken before treatment.Computed tomography (CT) scans were ordered in 4

    patients to rule out tumor, fractures, upper cervicadeformities, rheumatoid arthritis, and other postoperativeabnormalities. Transcutaneous Doppler ultrasound was alsoperformed to evaluate the condition of the vertebraarteries. Neck pain was evaluated before and aftermanipulation using the numeric pain scale (NPS) in alpatients (NPS: 0, no pain; 10, maximum pain).

    Chiropractic manipulation was only provided to patientswho presented with no neurovascular deficits and had noacute injuries. The chiropractic manipulative techniqueconsisted of high-velocity, low-amplitude (HVLA) thrust tothe upper cervical spine. The frequency and intensity ofcervical manipulation was delivered on a case-by-case basislargely depending on patients' tolerance to the manipula-tion. The age of the patient, cause, duration, and course ofthe arthritis were all taken into consideration when setting upthe frequency and intensity of manipulation. The following

    C1-C2 fusion,L lat masses;osteoarthritis

    5 M, 54 0 + 9 R latC1-C2 fusion;R lat masses;osteoarthritis

    Right 3 4 + 1 Poor None

    6 F, 42 0 + 10 + L latC1-C2 fusion;L lat masses;

    Left 1.3 7 + 1 Excellent Partial

    7 F, 43 0 + 1 + L latC1-C2 fusion;L lat masses

    Left 0.6 2 + 2 Excellent Full

    8 F, 32 0 + 3 + R latC1-C2 fusion;R lat masses

    Right 0.5 1 + 9 Excellent Partial

    9 F, 63 2 + 0 L latC1-C2 fusion;L lat masses;osteoarthritis

    Left 6 3 + 8 Good Partial

    10 M, 46 2 + 0 + L latC1-C2 fusion;L lat masses;osteoarthritis

    Left 2 2 + 3 Good Partial

    M, male; F, female; L, left; lat, lateral; R, right.l



    ,osttreatment results


    lation SideLength oftreatment (mo)

    Durationof follow-up(yr + mo)


    Reliefof pain



    Left 1.5 2 + 9 Excellent Partial


    Right 18 0 + 10 Fair Partial


    Left 1 6 + 6 Good Partial

    Left 6 1 + 10 Poor Partial

  • 133Yu et alJournal of Manipulative and Physiological TherapeuticsAtlantoaxial Osteoarthritis and Upper Cervical ManipulationVolume 34, Number 2principles were used when making a decision for the

    Fig 1. A 46-year-old man who had a head or neck injury 2 monthsbefore treatment. His chief complaint was pain on the left side ofhis neck. Physical examination found a reduction in ROM ofC1-C2 for rotation. Plain film radiographs showed the narrowingjoint space of the left atlantoaxial joint. The patient was diagnosedas posttraumatic atlantoaxial osteoarthritis.manipulation: higher frequency and lower intensity wereusually applied to patients whose symptoms were at theinitial stage or who were in the early stage of recovery frominjury. Once the symptoms were under control a differentfrequency of care, such as once a week, was used. Whentaking age into consideration, younger patients usuallyreceived higher intensity manipulation than older patients. Itwas important to observe and record patients' responses tothe first adjustment. In an attempt to reduce muscle tensiondue to neck stiffness because of neck pain, gentle neckmassage several minutes before the upper cervical manip-ulation sometimes was carried out. Subsequent to the uppercervical HVLA manipulation, all patients received asupplementary therapy performed by a mechanical device,(S.M.A.R.T Adjuster, TM SA201; Sigma Instruments, Inc,Cranberry Twp, PA). The device consists of a lever-actuatedmechanical jig and a pressure sensor so that it can detecttissue changes (temperature and density) thought to be aresult of reduced spinal segmental motion. The device cantransmit up to 20 lb/inch2 force impulse through apiezoelectric force sensor to mobilize joints. Because ofrelatively weaker muscles and a lower tolerance of painbetween C1 and C2, we applied different intensities of thedevice to different patients with different ages, for example,20 lb/inch2 for younger patients and 15 lb/inch2 for elderly.

    After a follow-up time (6-8 weeks), all patients underwentclinical and radiologic reevaluations. The following clinicaloutcomes were collected: pain location, if present; painintensity according to the NPS scale; cervical ROM of C1-C2rotation; and radiographic observations. Overall clinicalassessment was based on criteria,9 defined as excellent ifthe patient had no pain and C1-C2 activity was unlimited;good if there was slight pain and slight reduction in activity;fair if there was moderate pain, limiting daily activity; andpoor if there was no pain relief and symptoms were equal orworse than before treatment and severe limitation of activitybecause of pain. Pain assessment was evaluated using the NPSusing the following categories: noticeable improvement (NPSchange, N7), improvement (NPS change, 7-3), and non-improvement (NPS, no change). Open-mouth radiographicviews were used to assess the atlantoaxial facet joint space.

    Upon initial presentation, these patients with atlantoaxialosteoarthritis typically described the existence of localizedneck pain, often ascending to the occiput and radiating tothe frontal and temporal sides (intractable occipitocervicalpain). The pain was predominantly on the side of theosteoarthritic atlantoaxial joint. Head rotation was painfuland almost completely blocked in 3 patients and restrictedby more than 50% in the other 7 patients. Pain intensity on

    Fig 2. The same patient as in Figure 1 6 weeks after HVLAupper cervical adjustments combined with the device supple-mentary therapy. The patient indicated that he had relief of pain.Clinical examination also found improvement of C1-C2 rotation.Radiograph showed the restoration of joint space in the leftatlantoaxial joint.

  • unilateral atlantoaxial joint space narrowing with subchon-dral sclerosis. On the coronal CT scan in 3 patients, theaffected C1-C2 facet joint space showed narrowing withirregular margin.

    The patients were treated with HVLA upper cervicalmanipulation and followed with a mobilization devicesupplement treatment. After a series of treatments, thepatients reported pain relief. Average premanipulative NPSwas 8.6 (range, 7-10), which improved to a mean NPS of2.6 (pain relief differed from patient to patient, ranging from0 to 7) in posttreatment follow-up. Mean rotation of C1-C2at the end of treatment was improved from 28 (3.1) to 52(4.5). Two patients were graded as noticeable improve-ment in NPS pain assessment; both of them were youngpatients with posttraumatic atlantoaxial osteoarthritis.Overall, pain relief was more evident and faster in youngerpatients (n = 6) and in posttraumatic atlantoaxial osteoar-thritis (n = 6). These patients usually achieved excellent andgood ratings of criteria. Open-mouth radiograph of somepatients revealed recovery of joint space.

    In contrast, idiopathic degenerative atlantoaxial osteo-arthritis in more elderly patients (n = 4) required longer andmore intense treatment. Although temporary pain reliefcould be achieved after each manipulation, full pain relieftook as long as 10 months to achieve. Two patients in thisgroup were graded as nonimprovement in NPS painassessment. Generally, these patients could achieve good

    events reported that were related to the therapy for these 10

    spasm. Radiograph revealed complete narrowing of the leftatlantoaxial joint space (Fig 1). The patient was diagnosedas posttraumatic atlantoaxial osteoarthritis and receivedupper cervical manipulation combined with mobilizationtherapy. The patient had pain relief 1 week after thetreatment (NPS, 3/10) and continued improving during thefollowing weeks of therapy (NPS, 0-1/10). Evidentimprovement of ROM was found at the follow-up visit 6weeks later. Radiographic reevaluation also showed partialrestoration of the atlantoaxial joint space (Fig 2). Thepatient continued to receive the therapy until the outcomewas reported as excellent.

    Typical Idiopathic Degenerative Atlantoaxial Osteoarthritic CaseA 70-year-old woman had progressive development of

    right-sided neck pain 2 months before admission that was

    134 Journal of Manipulative and Physiological TherapeuticsYu et alFebruary 2011Atlantoaxial Osteoarthritis and Upper Cervical Manipulationthe NPS scale was more than 7 in all patients. All thepatients were neurologically intact. The standard open-mouth radiographic view before manipulation revealed

    Fig 3. A 70-year-old woman developed progressive pain on theright side of her neck. Clinical examination found almost norotation between C1 and C2. Radiograph revealed the narrowingjoint space in the right atlantoaxial joint.patients. Table 1 shows the demographic information,pretreatment conditions, and posttreatment results.

    Typical Posttraumatic Atlantoaxial Osteoarthritic CaseA 46-year-old man had a history of head/neck injury 2

    months before admission. He presented with left diffusemusculoskeletal pain in the neck and temporal regions. Theleft neck pain was rated as NPS 8 of 10; this was associatedwith reduced ROM of cervical vertebral, especially C1-C2rotation, tenderness in the left neck region, and muscleor fair results, but that required longer treatment period. Inaddition, radiographic recovery of joint space was notnecessarily associated with the relief of symptoms.

    Overall, 6 patients (4 traumatic and 2 degenerative cases)had substantial improvement in pain as well as partialrestoration of joint space after manipulation and supple-mentary therapy. There were no complications or adverse

    Fig 4. A CT scan of the same patient in Figure 3 showed erosionof the joint surface of the right atlantoaxial joint.associated with simultaneous onset of stiffness in the neck.There was no history of neck or head injury and any other

  • 135Yu et alJournal of Man...


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