Rheumatoid Arthritis and Cervical Instability and Neck Pain | Podcast Ep. 142

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. Before you adjust the next cervical spine in your practice, this is an episode that you are going to want to listen to because we're going to examine a piece of research which showcases a very common condition and a very high correlation to instability in the cervical spine. And this week's episode, as we talked about, is all about rheumatoid arthritis and cervical spine instability. Probably something that you were taught in school. I remember hearing it, but was not top of mind for me until I came upon this recent research paper and apologize in advance that I'm going to try to say the research does journal correctly. Rheumatologia, I believe. And it's in 20. That's the research journal Rheumatologia. And this paper was produced in 2017. Everything gets a lot easier to say after that. So the title of the paper was Cervical Spine Instability in the Course of Rheumatoid Arthritis. And it was all about the imaging methods actually. So great paper. Let's dive in a little bit and give some clinical context as well. Again, if you're seeing a patient and adjusting a cervical spine this this week, you're gonna wanna listen to this one. So we know rheumatoid arthritis historically hits about half of 1%, up to 1% of the population. So if you look at the United States and let's say there's 380 million people, that's a lot of people. We're talking millions of people suffering from ra. And when we think about it, I think all of us probably automatically think of the extremities, the hands, the knuckles, the disfigurement, the augmentation of those joints due to that chronic inflammation is very, very common. And that's what we see physically and literally see a lot of times with people with advanced ra. But what we also have to consider is the effects of that on the cervical spine and specifically the ligamentous structure and how that plays into your or my care with these individuals. So RA is a long term autoimmune disorder. You know, there's question marks as far as, you know, how much is genetic, how much is environmental in terms of how it comes on. And, and certainly it's an inflammatory type disease process. So with that or disorder, I should say so with that, anything that can reduce inflammation typically helps on the symptom basis. But there's nothing that I've seen to date as far as a reversal of ra. Let's Say so typically, these people are taking medications to mitigate symptoms. Ultimately, they're trying to decrease inflammation. And certainly I think chiropractic and chiropractors can play a significant role in that. Because when we look at decreasing inflammation, whether, whether that's through adjustments, whether that's through nutritional advice, whether that's through an adequate and really good active rehab and fitness program, there's a lot that we can offer to RA patients to help them get through their days better and a lot of benefits to their quality of life. I've never seen anything in the literature as far as chiropractic care, reversing RA or anything like that. But as far as being able to help people get through the day and making a big impact on their life, naturally, I think we as chiropractors have a huge role to play play in that. But there are a couple things that we want to keep in mind, certainly when taking care of these individuals. So as we've kind of alluded to, you know, the cervical spine instability is exactly one of those things that we want to be cognizant of when taking care of individuals with ra. And I say this because I'm thinking about it from a clinical context and a workflow context in your practice, you might have a patient come in that doesn't mark it down on their initial intake form, and perhaps it's not advanced enough where you notice it on their knuckles or on their hands. So this is an important thing and it's a fine line. I'm not suggesting that you need to ask every single person whether they have RA when they come into your practice, but I think it's something we all are gonna wanna keep top of mind as we see patients. Again, 1% of the people statistically that came into your office have had ra, you know, so if you've seen a hundred patients in your career, there's one there. If you've seen a thousand patients, you know, there's 10. If you've seen 10,000 patients, there's quite a few there that have had RA. Now, here's where that breaks down and becomes really clinically significant. This research paper found that in 65%. Let me repeat that 65% of individuals with rheumatoid arthritis, there was instability typically between C1 and C2, 65%. So that means about half of 1% of the time you have a patient coming in with an unstable cervical spine due to rheumatoid arthritis, that's significant. I don't say that to scare you. Probably Thinking about your numbers, right. How many patients have I had in my practice and how many probably statistically have had rheumatoid arthritis and instability of the upper cervical spine? It's something that we all want to keep in mind. I think it's something that we're all going to want to certainly be asking good questions about. And absolutely, if patients, during their history, something doesn't seem right. It seems like they might have an autoimmune type disorder, but it's never been properly diagnosed. These are good instances where RA could be used as a differential diagnosis to be able to help the patient in the best way possible and certainly first and foremost, to do no harm with your care. So what this research paper also looked at, which I found very, very interesting, were the advantages and disadvantages of the radiographs of checking out the upper cervical spine. So when we take an X ray, a CT scan, or an Mr. Scan, which one was best? What are the advantages? What are the disadvantages for using each for patients with rheumatoid arthritis? And I'll run through that really quickly with you because I think it's important for us to keep in mind clinically. Again, they looked at X ray and some of the advantages for taking X ray for cervical spine lesions, as they said, easily accessible, right? X rays are all over the place. Low cost, they're cheap, low radiation dose compared to the others. Super low radiation. Get the X ray takes a second, less than a second, certainly possibility of imaging inflection, extension, which is also good to be able to see that stability or instability. And certainly they're sufficient to assess the location of the vertebra. You can see if something's been completely eroded. Absolutely. By taking an X ray. So there's all the advantages of X rays, some of the disadvantages. Assessment of the details is very difficult, especially the atlantoaxial joint, as they know. And there's no possibility to assess non calcified structures. So soft tissue, spinal cord, pannus, these things are just not imaged very well at all with an X ray. So you're missing a lot of the equation. But as far as accessibility, as far as cost and as far as what you can get out of it, X ray's a great tool to analyze stability of the upper cervical spine and see what's going on specifically with your patients with radiation. CT scan, couple advantages, couple disadvantages. It's the best method, as we know, to check out the bones, right? The vertebrae themselves. Useful in planning surgical treatment if something's gone that far, if there's erosion to the point or instability to the point where a surgery is necessary. Typically CT is going to be ordered if that patient has ra. Disadvantages of ct, high cost in comparison with an X ray, higher radiation dose certainly than an X ray and difficulty in assessing the soft tissues. Right. Connecticut is meant for bone mri as we'll talk about in a moment. Best on soft tissue. So ct, you don't get the best view of those soft tissues and. Mr. You know, advantages there. Best method for soft tissues in spinal cord assessment, see if there's any damage, see what's going on with the nervous, you know, the nervous system itself. Best method of analyzing that. High sensitivity and specific specificity to instability assessment. You can really see what's going on as far as the soft tissue's concerned. And that can help with your analysis. Absolutely. And another advantage of. Mr. The it's the method of choice for patients with neurological deficits. If you're seeing something, of course, where there is a neurological issue going on. Mr. Is typically the first thing that's gonna be ordered, whether it's a full brain scan and cervical spine just to C spine. We all have done that many, many times in our careers, I'm sure. Disadvantages of the. Mr. It's the most costly. I mean, that varies wildly depending upon where you live in the country, but it's pretty darn costly. There's contraindications, right? You have patients that have had implants, any metal in their body. There's just a lot of contraindications compared to the other the long exam duration. You gotta sit in the tube for a while. It's just pragmatic from a patient flow perspective. And in some cases sedation can be necessary if somebody's super claustrophobic or you just can't get that scan any other way. So that complicates the picture. But with all that being said, what the researchers come to as a conclusion is that, hey, X ray is a great first line tool and every single imaging modality has its advantages, has its disadvantages. Just as with if you're shooting it for a patient with RA or if you're shooting it for a patient with any other type of disease or disorder. There's advantages and disadvantages of every imaging type. But X ray holds its own as far as having accessibility, as far as having low cost, low radiation dose and being able to check out what's going on in that upper cervical spine. X rays are great frontline defense, which again is something that we can take note of because many of us have X ray in our practice or we have X ray very close to our practice and great relationships with those X ray providers or imaging centers. So again, couple things to keep in mind from a clinical perspective this week in your practice. 1% of individuals have RA. Half of them have clinical instability of that upper cervical joint. Before you get in there with a rotary break, a gonstead, you know, a toggle, a diversified adjustment, you definitely wanna be cognizant of what's going on in that upper cervical spine. If there is any question whatsoever of ra, I would highly encourage you based upon the patient of to get those images done, check out what's going on so you can be comfortable and confident moving forward. And really, again, I say this from the place of I believe chiropractors have a huge opportunity to help people with RA improve their quality of life, see life impact benefits in their day to day. But we wanna make sure that we are being diligent and we are being thorough on the front end to make sure that we get those outcomes on the back end. So I hope you have a great day in practice. If you have not left us feedback or rating on itunes, I would ask you to do so. If you have any comments, questions or future topics that you'd like to hear us talk about, hit me up jeff@the evidencebasedchiropractor.com and I will talk to you soon.

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