Radiotherapy in arthritic conditions

Abstract

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