Ashley Rolley, SPT
Osteoarthritis of the spine is a condition in which degeneration of the facet joints occur1. Also known as Spondylosis, OA is a result of normal "wear and tear." The cartilage between the facet joints breaks down. As the degeneration occurs in the cartilage, the bone of the joints is damaged, causing osteophytes to form, resulting in pain, stiffness, and decreased movement2. Osteoarthritis is usually found in conjunction with degenerative disc disease.
Below you will find several aspects pertaining to spinal OA, including diagnosis and treatment.
The anatomy of the spine consists of several different structures working together to create a stable structure to hold humans in an upright position. These structures consist of:3
- Facet joints
- Intervertebral discs
- Spinal cord and nerves
- OA is the #1 cause of disability in America2.
- Close to 50 million people in the United States have osteoarthritis in at least one joint of the body1.
- The incidence of spinal OA is not known, but is estimated to be very high.
- Spinal OA is most often seen in the cervical and lumbar regions
- 50% of people age 65 or older have OA in at least one joint1.
- 60% of men and 70% of female over the age of 65 have OA1.
- More prevalent in men age 45 and younger, but more prevalent in women age 50 and older1.
The majority of patients with spinal OA can experience several of the following signs and symptoms1,2,4:
- Back pain (described as aching, usually unilateral, but can also be bilateral as symptoms progress)
- Pain with extension
- Pain is decreased by lying down
- Localized tenderness
- Stiffness (decreased range of motion)
- Muscle weakness
- Muscle spasms (can lead to an abnormal curvature)
- Referred pain
- Neurological symptoms due to nerves being irritated by swelling and/or compressed due to osteophyte growth
- Weakness in arms/legs
The pain and stiffness is increased during longs periods of inactivity. Patients will complain that they have the greatest amount of stiffness and pain upon waking in the morning. Pain and stiffness usually decreases after about a hour, but may return upon increased activity during the day1.
The cause of OA is not yet known, but certain factors increase the risk of developing OA1,2:
- Heredity- a family history of OA can increase the chances
- Joint trauma- trauma can cause the joint to not function properly, adding extra stress to the joint
- Overweight- being overweight can cause more stress on the spine, increasing the "wear and tear"
- Repetitive use- overtime the joints can become damaged from overuse.
- Aging- normal "wear and tear" is part of the aging process
- Female- OA is more common in post-menopausal women
- Associated diseases- diabetes, infections, Gout, and/or RA.
Each of these factors can cause excess "wear and tear" on the joint surface, leading to the degeneration of the cartilage.
X-rays can indicate formation of osteophytes and a decrease in disc height. They can also identify if spinal stenosis has occurred as a result of OA. However, they are not as valid as CT scans or MRI's. X-rays are not able to show early signs of damage to the cartilage1,4,5.
CT scans can identify more subtle bony changes, but are still not as valid as MRI's because they do not show changes in other structures1,4,5.
MRI's can identify disc, ligament, muscle, or nerve abnormalities. MRI is the gold standard for diagnosing OA because it can identify abnormalities in every surrounding structure1,4,5.
The presence of osteophytes, decreased disc height, nerve compression, and/or narrowed spinal canal would support the hypothesis of OA.
- A subjective evaluation is performed to get past medical history and clues that may confirm a hypothesis of OA. Clues such as stiffness and pain upon wakening with a decrease after a hour and the patient's age being over 65 can help confirm the diagnosis (these symptoms do not necessarily mean that the patient has OA)3,6.
- Ask special questions pertaining to the lumbar or cervical region6.
- Observe the patients posture and gait in order to get a sense of what the issue is (look for really obvious abnormalities)3.
- Movement tests such as flexion, extension, rotation, and etc should be performed to find the comparable sign3.
- Consider ruling out the SI joint and the hip as possible issues that may be causing referred pain to the lumbar, and the shoulder that may be causing referred pain to the cervical region3,6.
- Perform a neurological exam including: myotomes, dermatomes, and reflexes if the patient is complaining of numbness and tingling in the extremities. The conclusion of the neuro exam can help identify which vertebral level is problematic3,6.
- Slump tests, straight leg raise test, and/or upper limb tension tests, can be used to see if there are any signs of nerve tension6.
- Palpation should be performed to find points of tenderness, spinal abnormalities, exact location of pain, and/or muscle spasms. Once specific areas are identified as problematic, the treatment can be focused on those particular areas6.
Following the Maitland approach to evaluation and treatment is explained more thoroughly in the Fundamentals of Maitland Mobilizations section.
Conservative treatment is successful 75% of the time5. Treatment can start with NSAID's, topical medications (Ben-gay and Aspercreme), and/or muscle relaxants to alleviate the pain5. Massage therapy can be useful to decrease muscle spasms and inflammation.
Physical Therapy sessions will focus on regaining lost ROM and strengthening the paravertebral and abdominal muscles. by strengthening the abdominal muscles, there will be more support for the spine. If movement is painful and/or not tolerated, strengthening should be conducted doing isometrics, then slowing progressing to concentric and eccentric1,4,5,7.
Low impact exercises (swimming and walking) are beneficial because they do not add an increased amount of stress to the joint7. Aquatic therapy is extremely beneficial for patients with OA7.
The vertebrae can be mobilized to help reduce pain and decrease stiffness. PAIVM's such as central and unilateral PA's can be performed in grades I and II for pain relief and grades III and IV to decrease stiffness6.
Encouraging the patient to lose weight can dramatically improve their condition. Weight loss of 15 pounds can potentially cut the pain in half7.
Although the “wear and tear” of arthritis cannot be reversed, the symptoms associated with spinal OA can be alleviated.
Cryotherapy removes heat from the body and decreases tissue temperature. In the form of ice packs, ice massages, or cold packs, it decreases blood flow, which will reduce inflammation, edema, muscle spasms, and tissue metabolism8. Cryotherapy also provides a local anesthetic sensation by decreasing the threshold of nocioceptors in the tissues and the conduction velocity of the pain signals8. The negative side effects to cold include decreased extensibility, slowed wound healing, and potential for frostbite.
Thermotherapy adds heat to the body increasing the tissue temperature. Thermotherapy involves adding to heat to increase the flow of blood to a specific site. Heat can decrease pain, spasms, and increase tissue metabolism and extensibility8. Heat allows for a faster healing process due to the increased metabolism, which causes increased inflammation and edema. Recent studies have shown that heat wraps are more efficient for long term reduction of low back pain than acetaminophen or ibuprofen8.
Transcutaneous electrical stimulation delivers an electrical current through the skin via electrodes. TENS works by overstimulating the A-beta nerves in order to mask the pain signal caused by A-delta and C fibers (gate control theory)9. Low current amplitudes and shorter pulse durations are needed to depolarize sensory nerves. Patients with chronic low back pain have found it beneficial to wear TENS for long periods of time to help reduce the pain10.
OA can cause muscle spasms which can contribute to Low back pain. Both Heat and Cold packs can reduce the muscle spasms and pain. OA also causes stiffness; heat will aide in decreasing the stiffness.
There have not been studies that look at specific modalities for spinal OA, but there have been many studies that look at modalities for OA in the extremities. A systematic review11 looked at 23 studies that focused on different modalities for knee OA. The results indicated that there was a reduction in pain after the use of TENS (moderate quality evidence)11. The results of the studies that focused ultrasound, heat and cold packs were inconsistent and unclear11.
Based on the reasoning behind the use of each of these modalities, it is understandable that they may help alleviate the symptoms of OA, however there is not enough research to confirm any one modality being better than the other.
Surgery and Post-Op Treatment
Surgery is very rarely used for patients with spinal osteoarthritis. Surgery is not considered until conservative treatment is tried and fails1.
Surgery may be needed or recommended to correct or prevent more damage from occurring. In less-invasive sugeries osteophytes can be shaven off arthroscopically. Some patients undergo osteotomies, joint resurfacing, and worst case scenario: spinal fusion12. Some patients can have surgery that replaces damaged vertebrae with prosthetics, to prevent further destruction of the catilage12.
As with most spinal surgeries there are several precautions to keep in mind. Patients should avoid lifting, bending, and twisting until precautions are lifted by the surgeon. Light exercise, such as walking, and eating healthy are important to help bones and incisions heal12.
Physical therapy will also be needed to help regain strength and ROM after surgery.
Some tips to prevent OA and/or slow the progression include4,5,7:
- Sleep on a medium-firm mattress
- Maintain a proper weight
- Wear well supported shoes
- Engage in exercise to maintain strength and flexibility
- Use good body mechanics
- Know when to take breaks
- Apply heat to reduce stiffness
- Apply ice to decrease pain
- Eat healthy well balanced meals
- Take dietary supplements such as glucosamine and chondroitin
- STAY ACTIVE!!!