Conservative Management of Low Back Pain and Scoliosis in a Patient With Rheumatoid Arthritis: Eight Years Follow-Up

Abstract

Scoliosis in patients with rheumatoid arthritis (RA) can cause significant pain and disability. RA has been extensively studied in relation to the cervical spine, yet the pathology of the thoracic and lumbar spine in RA patients has been largely overlooked. A 66-year-old woman, with longstanding RA and severe scoliosis, presented to the chiropractic clinic with a five-month history of exacerbated low back pain radiating to the right lower limb. The patient was treated with a combination of full-spine mechanical spinal distraction, spinal manipulative therapy, mechanical distraction of the cervical spine, and soft tissue treatment (scraping therapy). Thereafter, the patient recovered from the pain and radiculopathy and showed improvements in the radiological parameters, walking gait, and postural balance. Radiography was performed at the 12-month, four-year, and eight-year follow-up appointments and revealed improvements in symptoms, posture, and scoliosis. Although the treatment for RA-related scoliosis is similar to that for other types of scoliosis, due to the nature of RA, treatment should be tailored to individual patients. This case report highlights the importance of considering chiropractic therapy for the management of lumbar scoliosis in patients with RA, as a comprehensive treatment plan resulted in improved spinal balance, mobility, gait, posture, and quality of life.

Keywords: chiropractic management; chiropractic therapy; inflammatory disease; rheumatoid arthritis; scoliosis.

Figure 1. Full-spine radiograph and lumbar magnetic resonance image

A) Full-spine radiograph revealing degenerative changes in the thoracic and lumbar regions, shoulder and pelvic imbalance (dash white line), and abnormal thoracic and lumbar scoliotic curves. The Cobb angle was measured at 60 ° (red lines) B) At L4-5 (white arrows), there are spondylolisthesis, posterior bulging disc, and marked bilateral facet joint degeneration, in the right facet joint and ligamentum flavum hypertrophy causing mild indentation of the thecal sac. Diffuse bulging disc and osteophytes at L2-3 causing mild indentation of the thecal sac, mild right lateral recess and mild bilateral foraminal stenosis. No nerve root compression is seen.

Figure 2. Photo of patient's hands

Her hands show Heberden (yellow arrow) and Bouchard nodes (red arrow) on the fingers.

Figure 3. Mechanical spinal distraction demonstration on scoliosis

The patient is positioned in supine on the distraction device (Spine MT, Shinhwa Medical, Korea) with the head, thoracic, and pelvis stabilized via straps. The knees are in flexed position. A distraction and rotation force (20% of the body weight) is applied for 15 minutes.

Figure 4. Full-spine radiographs at the 12th month and eighth year re-evaluations

A) At the 12th month, radiographs showed improved spinal curvature and posture, as well as halted scoliosis progression. Shoulder is more balanced, and the Cobb angle was reduced from 60 ° to 50° (red lines) B) At the 8th year, the thoraco-lumbar scoliosis and shoulder (dash white line) and pelvic imbalances showed improvement.  The Cobb angle was stable at 48 ° (red lines)