Case report Upper cervical instability associated with rheumatoid arthritis: What to ‘know’ and what to ‘do’ Helen Slater a, b, * , Andrew M. Briggs a , Robyn E. Fary a, b , Madelynn Chan c a Curtin Health Innovation Research Institute, Curtin University, Australia b School of Physiotherapy, Curtin University, Australia c Royal Perth Hospital, Perth, Australia article info Article history: Received 19 December 2012 Received in revised form 18 January 2013 Accepted 19 January 2013 Keywords: Rheumatoid arthritis Systems screening Red flags Risk benefit analysis Triage Cervical spine instability abstract This case report describes a patient who presented with cervical spinal pain and headaches associated with atlanto-axial subluxation (AAS) secondary to rheumatoid arthritis (RA). For physiotherapists, especially less experienced clinicians, the significant risks associated with using manual assessment and treatment techniques in such a patient require careful consideration right at the start of a consultation. The focus of the case is therefore on the recognition of AAS in this patient with RA, highlighting the clinical findings that alert clinicians to this possibility and explaining the requisite knowledge and skills required to safely and effectively manage this patient. The use of screening tools to help clinicians identify possible RA in its pre-diagnosis stage and the clinical signs and symptoms that raise the index of suspicion for AAS, are discussed. The relevant contraindications and precautions associated with manual treatments directed at the upper cervical spine, and which may have potentially serious negative con- sequences, including quadriplegia and mortality, are addressed. Finally, the implications for the use of manual assessment and treatment of patients with RA and co-morbid AAS are addressed. Ó 2013 Elsevier Ltd. All rights reserved. 1. Introduction For physiotherapists using manual treatments in the assessment and management of patients with rheumatoid arthritis (RA), awareness and identification of potentially serious articular and peri-articular manifestations of the disease, including instability of the cervical spine, is essential. While there is a need for vigilance with respect to extra-articular manifestations of RA (see accom- panying Professional Issue by Briggs et al., 2013), this paper focuses on the upper cervical spine. The most frequently occurring insta- bility in the cervical spine is anterior atlanto-axial subluxation (AAS) (Wasserman et al., 2011; Yurube et al., 2012), where progressive loss of the primary and secondary ligamentous integrity combined with bony erosion of the odontoid process, associated with systemic inflammation as part of the RA disease process, can result in dire consequences, including quadriplegia or death (Paus et al., 2008; Wasserman et al., 2011). A high index of suspicion for AAS in patients with RA should alert clinicians to the potential risks associated with manual assessment and treatment and help ensure safe and effective patient care. The following case report on a patient with RA and associated AAS takes a clinical practice focus, highlighting the importance of the requisite clinical knowledge, reasoning and skills required to guide appropriate assessment and management. 2. Case report 2.1. Clinical history A 55 year-old female with a 35-year history of seropositive RA was referred to physiotherapy for assessment and management of persistent, bilateral neck pain and headaches (Fig. 1). The neck pain radiated bilaterally from the suboccipital area to occipital and parietal areas, with occasional shooting pain to both temples. She described hearing “clanking” and "crunching" sounds in her neck, mainly on neck flexion or extension. The pain had been present for five years, with recurrent episodes of increased neck pain associated with increased bilateral suboccipital/occipital and parietal headaches. The neck pain and headaches had noticeably worsened in the past two years and coincided with a change in her occupational duties, which involved increased computer work requiring more sustained postural demands and more frequent and repeated flexion/extension movements of the head and neck. Pain was rated as moderately severe (average visual analogue scale * Corresponding author. School of Physiotherapy, Curtin University, GPO Box U 1987, Perth, WA 6845, Australia. Tel.: þ61 8 9266 3099; fax: þ61 8 9266 3699. E-mail address: H.Slater@curtin.edu.au (H. Slater). Contents lists available at SciVerse ScienceDirect Manual Therapy journal homepage: www.elsevier.com/math 1356-689X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2013.01.005 Manual Therapy 18 (2013) 615e619