Radiotherapy in arthritic conditions

RADIOTHERAPY

IN

ARTHRITIC

CONDITIONS

I8I

R A D I O T H E R A P Y IN ARTHRITIC CONDITIONS BY G. D. KERSLEY, T.D., M.D., F.R.C.P. ROYAL

NATIONAL

HOSPITAL

FOR

RHEUMATIC

DISEASES~

BATH

EVERYONE admits that radiotherapy is of value in ankylosing spondylitis although no one really knows how it acts. In other types of arthritis the value of X rays has been, in the past, a matter of opinion. In order to try to learn more about this subject, Dr. Desmarais, at that time one of my Unit, collaborated with Dr. Flemming under a grant from the Nuffield Foundation to investigate the problem. Sokolow in 1897 and Stenbeck in i898 were the first to use X rays in the treatment of joint disease. Since then many encouraging but conflicting reports have been published regarding the value of X rays in different arthritic conditions. Most of the reports, however, except for those of Smyth, Freyburg, and Peck (i94I) and Kuhns and Morrison (i946), were not based on carefully controlled experiments. They agreed about the beneficial effects of X rays in ankylosing spondylitis and osteo-arthritis, but they were not in agreement regarding the results in rheumatoid arthritis. In our experiment, routine physical treatment was given to all patients, and I should like to emphasize at this point the need for radiotherapy to be combined with other treatment and general advice on the management of the patients' daily routine for the result to be satisfactory. For instance, if X-ray treatment temporarily eases pain in an osteo-arthrific joint, unless advice is given about the methods required to save yet mobilize the joint, the patient will take advantage of any analgesia, still further to misuse the joint, and the end-result may be worse than at the beginning. Advice will depend, of course, on the joints involved. In the patient who is fair, fat, and forty, with painful knees, weight reduction and quadriceps drill will be the order of the day. The sportsman with a bad hip must cut out his excessive walking and should do some ' back cycling ' to keep up mobility. The housewife with backache must have a stool of the right height in the kitchen and carry out postural, mobilizing, and strengthening exercises regularly each morning. A spinal belt may also help her. Heat will ease pain in an exacerbation and massage may deal with concomitant ' non-articular rheumatism '. Let us remember that radiological changes and pain often do not correlate at all well and that attention to the soft tissues may provoke a cure in spite of the presence of osteophytes. Again in spondylitis, unless the respite obtained by radiotherapy is utilized to improve posture and is followed by the use of a light brace and instruction on the importance of the recumbent posture, the long-term gain will be but slight. In a severe and active case a plaster bed at night, postural and breathing exercises, and a rest, flat on the back on a firm surface, at midday are necessary. Without this the value of radiotherapy will be entirely lost. Team work is required in diagnosis, preparation of the patient, treatment of anaemia, mapping out a general treatment and concomitant physiotherapy, discussion on X-ray dosage, sometimes the application of surgery, and finally, perhaps adjustment of occupation. The physician, orthopaedist, pathologist, radiologist, radiotherapeutist, physiotherapist, and welfare officer should all have their place in the team, though the part they will play will vary according to the particular case under treatment. The present series of 788 cases was first divided into those due to osteo-arthritis, rheumatoid arthritis, ankylosing spondylitis, and spondylitis with peripheral joint involvement. Each group • . . . ~ , was then broken down by random samphng mto high-voltage therapy (H.V.T.)--hlgh C , medium ' B ', and low dosage ' A ' - - a n d controls, and m . the . rheumatoid . . arthrmc . and . Spondylmc

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group also a low-voltage therapy (L.V.T.) sub-group was included (Table I). T h e controls were placed on the couch under the machine, but the current was not switched on. T h e physical factors of H.V.T. were 220 kV. and 15 mA. with a H.V.L. (half-va!ue layer) of i. 5 ram. of copper and F . S . D . (focal skin distance) of 5 ° cm. T h e filter was I ram. Cu and I ram. A1. T h e size of the field varied with the areas treated. T r e a t m e n t was given twice weekly for three or four weeks to all areas except the spine. I n the case of the larger joints the total weekly mid-joint dose of 25o r was never exceeded and for the smaller joints the total dose was always fractionated.

Table /.--DosAGES H.V.T. L.V.T.

REGIONS

CONTROL

A

B

C

Spine Hip

500

iooo

i5oo 2000

Knee Ankle

500

750

iooo

Nil

Elbow

500

6oo

8o0

Nil

Wrist Tarsal

300

400

500

Nil

Interphal.

IOO

200

300

Nil

300

Nil

T h e spine and sacro-iliac joints were divided into five fields and each field was treated twice weekly with an average dose of 300 skin r per week. On this programme the course lasted between four to six weeks. I n young female patients glancing fields were used to irradiate the sacro-iliac joints. T h e physical factors of L.V.T. were i4o kV., 5 mA., with a H.V.L. of 7"5 ram. A1, and F.S.D. of 25 cm. with filter 0.25 mm. Cu and I mm. A1. T h e vertebral column was irradiated through a strip io cm. wide over the spine and 15 × 15 cm. over the sacrum and sacro-iliac joints. T h e whole area was given 5 ° skin r twice weekly for three weeks to a total dose of 30o skin r. O s t e o - a r t h r i t i s . - - O s t e o - a r t h r i t i s may be looked upon, from the practical point of view, as the result of wear and tear on joints sometimes of poor calibre. Quite recently this condition has been divided by some into an oligarticular and an acute generalized type, a distinguishing feature of the latter being apophyseal rather than osteophytic involvement of the spine. At the time of our experiment this classification had not been suggested and therefore no serious attempt was made to break down our cases into sub-groups. T h e results obtained in the 429 cases of osteo-arthritis are shown in Table H. I t is evident that the results of treatment of the cases treated by the small and m e d i u m doses are not significantly different when compared with the control group, the value of P in each group being more than "o5. W i t h the larger dose, ' C ', however, there is definite evidence that the response to treatment is better ; 59 out of io2 cases were improved, of which 41 cases showed marked improvement. This is statistically significant, the value of P lying between .05 and .o2. On review after six months and one year, 98 per cent (57 out of 58 ) and 79 per cent (41 out of 52 ) of these cases respectively had maintained the improvement originally noted at three months.

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CONDITIONS

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It was interesting to observe that the different parts of the spine did not respond equally to treatment. Of I I i cases in this group the best results were obtained in the dorsal region in which 69.2 per cent of the cases showed a marked improvement. I n the cervical region such improvement was obtained in 45-8 per cent, b u t the response in the lumbar region was in only 21.6 per cent. The age of the patient, the duration of the disease, and the extent of the radiological changes had no apparent influence on the therapeutic result. Increase in the range of movement and improvement in function generally accompanied the improvement in pain, unless gross mechanical obstruction was present.

Table //.--OsTEO-ARTHRITIS DOSAGE

NUMBER OF CASES

PERCENTAGE

Nil

Slight

Marked

89

54

12

z3

"5o>P>'3o

50"5

i82

88

35

59

"lo>P>'o5

51"6

I02

43

18

41

"05 > P > -oz

57 '8

35

9

12

A

C

IMPROVEMENT IN DEGREE OF PAIN

~ontrol

56

IMPROVED

37"5

Ninety-one cases in the treatment groups ' B ' and ' C ' were re-examined radiologically at the end of six months. T h e r e was no evidence of obvious changes in 84 cases and in 7 the appearance had deteriorated slightly. Ninety-two cases with symmetrical joints equally involved received different doses to each joint. Comparison of the results in the groups showed that the higher doses ' B ' and ' C ' were nearly twice as effective as the small dose and the control group combined. Table IlL--RHEUMATOID

ARTHRITIS

(Excluding Spine and L.V.T.) IMPROVEMENT IN DEGREE OF PAIN

NUMBER OF CASES

Nil

Slight

Marked

6i

37

13

II

"5o>P>'3o

39'3

7o

42

I3

15

•5 o > P >

40'0

C

76

4o

14

22

",o>P>-o5

Control

5o

35

DOSAGE

A

12

PERCENTAGE IMPROVED

'30

47"3 30"0

R h e u m a t o i d A r t h r i t i s . - - T h e results obtained in the rheumatoid group were disappointing. It must be pointed out that the majority of the cases treated were in the reactive stage and showed radiological evidence of secondary osteo-arthritic changes. There were 257 cases in this group and the results obtained with each sub-group showed no significant difference when compared with those obtained in the control group, the value of P in each being more than .o 5 (Table III). T h e response to the larger dose ' C ' was slightly better than that of the small and m e d i u m doses. I t is possible that the osteo-arthritic element in these cases may have influenced the results.

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Ankylosing S p o n d y l i t i s . - - I n the ankylosing spondylitis group the response tO treatment was more dramatic. T h e disease being relatively less common than rheumatoid arthritis and osteo-arthritis, the n u m b e r we have had the opportunity of treating has been correspondingly smaller. Of lO2 cases on our list, 7 ° cases received treatment to the spine and in 3 2 cases the treatment was directed to areas other than the spine. (Tables IV, V.) T h e results obtained in the spinal cases treated by the doses ' B ' and ' C ' were excellent, the results with the larger dose ' C ' being

Table /V.--ANKYLOSING SPONDYLITIS (Spine)

DOSAGE

A

LVT

NUMBER OF CASES

IMPROVEMENT IN DEGREE OF PAIN

Nil

Slight

PERCENTAGE IMPROVED

Marked

I4

•2 o > P >

'io

64

5

88

I7

13

•I o > P > ' o

I9

17

"o2>P>'oI

95

"7o>P>'5o

45

II

~ontrol

44 Table

V.--ANKYLOSING

SPONDYLITIS

(Other Sites)

DOSAGE

NUMBER OF CASES

IMPROVEMENT IN DEGREE OF PAIN Nil

Slight

Marked

A II

Control slightly better than the dose ' B '. T h e response of the cases in the dosage group ' A ' was less satisfactory when compared with the controls, and the cases treated by the L.V.T. failed to respond altogether. T h e relief of pain was usually experienced halfway through the course and reached its m a x i m u m a few weeks after completion of treatment. All the cases which improved on the dosages ' B ' and ' C ' had maintained their degree of improvement at the one year. Pain was relieved irrespective of the stage of the disease. Increase in mobility of the spine commonly followed relief of pain in cases with minimal radiological changes, but was not apparent in advanced cases with ligamentous calcification. Of 52 cases re-examined radiologically after six months 44 showed no material change. In 6 cases the disease had progressed in spite of relief of pain and improvement in the general condition of the patient. I n 2 cases only was there some radiological evidence of improvement.

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CONDITIONS

i85

When the results of the other sites were analysed, the response was also very good with the doses ' B ' and ' C ' b u t slightly better with the bigger dose. When the mean value of the sedimentation rate, h~emoglobin, and weight of all spondylitic cases before treatment was compared with the mean value at six weeks, three months, six months, and one year after treatment it was found that there was a tendency for the E.S.R. to fall and for the weight to increase steadily (Table VI). T h e r e was no appreciable change in the h~emoglobin level over that period of time. T h e increase in the E.S.R. immediately following treatment as reported by many authors was not apparent in this series. Table V I . - - A N K Y L O S I N G SPONDYLITIS

Average E.S.R., H~emoglobin, and Weight in Treatment Groups B and C AFTER TREATMENT

BEFORE TREATMENT

6 weeks

3 months

6 months

I year

E.S.R. (Westergren)

55 '5

49'9

52"2

44"1

35"3

H~emoglobin (G)

I2"2

1 I'6

I2'I

11"6

12'2

st. lb. 9 io

st. lb. 9 II

Weight

st. 9

lb. 9

st. 9

lb.

st. lb.

12

io

3

I stated earlier that in young female patients glancing fields were used to irradiate the sacro-iliac joints, but even this is best avoided except in those with very severe low back involvement. Ankylosing spondylitis is a disefise that varies in severity from formes frustes with only occasional slight backache to a severely crippling disease, but even in the worst case good results can usually be obtained with care of posture. W h e n child-bearing is likely, Butazolidin in small doses, or, during correction of deformity, A C T H or cortisone for a short spell is preferable to radiotherapy. These measures are also most valuable when the maximum safe dose has already been given to male patients. Let us here remember how often cases of osteochondritis juvenilis and even patients with hysterical pain are referred as cases of spondylitis. It is difficult to imagine a more harmful treatment than the irradiation of the ovaries of such a patient.

CONCLUSIONS No explanation of the mechanism whereby X rays affect the tissues and relieve pain has been demonstrated and the subject is still a controversial one. Summarizing the above results we can definitely state that X - r a y therapy has a place in the treatment of certain arthritic conditions. T h e best results are obtained in the treatment of ankylosing spondylitis. T h e relief of pain is dramatic, and following radiotherapy the general condition of the patient tends to improve, then giving an opportunity to the physician to apply other forms of corrective treatment with greater comfort to the patient. In our experience it is felt that doses larger than 15oo skin r directed to the whole of the spine and the sacro-iliac joints are not necessary and in some cases good results may be obtained with i2oo r. One advantage of this dose is that treatment can safely be repeated in six months if necessary, and the dangers of affecting the skin and marrow are practically nil. Another advantage is that hydrotherapy can also be given at the same time without any risk of damage to the skin. M u d packs and counter irritants are, however, avoided.

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Whether the treatment arrests the progress of the disease is a debatable question. A definite opinion can only be reached when someone is ' brave ' enough to carry out a careful and more prolonged follow-up of cases and controls. From our results, however, we can see little evidence so far that deep X-ray therapy materially alters the evolution of the disease. I n view of this the question arises as to whether treatment should be confined to the part of the spine producing symptoms. One interesting point is that it is not unusual for the peripheral joints in spondylitis to obtain benefit from radiotherapy, whereas this is not the case in rheumatoid arthritis--one more possible distinction between rheumatoid arthritis with spinal involvement and true spondylitis ankylopoietica. The response of some cases of osteo-arthritis to deep X-ray therapy is also favourable, and the relief of pain is sometimes dramatic with fairly large dosage. Certain cases, however, fail completely to respond and the reason for this is not at present apparent. Dausset and Lucy (193o) observed that cases in which osteophytic lipping was predominant responded better than the cases with loss of cartilage, sclerosis, and cyst formation, but we have not been able to confirm this observation. Our results in the treatment of rheumatoid arthritis have been disappointing. Only when a few larger joints are involved and there is a superimposed osteo-arthritic process does radiotherapy seem to be justified. In conclusion, deep X-ray therapy is only a local treatment and the care of the patient on general medical lines must never be neglected. As an adjunct to physiotherapy, hydrotherapy, and orthopmdic measures we believe that in selected cases much can be done by radiotherapy to ease the patient's pain and improve his well-being and also facilitate and accelerate his rehabilitation programme. REFERENCES DAUSSET,I., and LucY, J. (193o), Paris todd., I, 112. KUttNS, J. G., and MORmSON, S. L. (I946), New Engl. ff. Med., 225, 399SMYTrL G. G., FREYBURG,R. H., and PECK,W. S. (I94I),ff. Amer. med. Ass., II6, 1995. SOKOLOW,A. (I897), quoted by KAHLMETER,G. (I93O), Brit. ff. Actino. Ther., 5, 93. STENBECK(I898), quoted by KRONENBERGER,P. H. (t945), Med. Bull., Bombay, I3, 45-