Cervical Myelopathy Rehabilitation Protocol

This protocol provides a guideline for the rehabilitation of patients diagnosed with Cervical Myelopathy. Individual patient progress may vary, and the protocol should be adjusted based on the patient's specific presentation, functional limitations, and response to treatment. Collaboration with a physician or surgeon is essential.

Pathophysiology

Cervical myelopathy is a condition characterized by compression of the spinal cord in the cervical region. This compression can be caused by several factors, including:

• Degenerative Changes: Spondylosis (osteoarthritis), disc herniations, and facet joint hypertrophy.
• Spinal Stenosis: Narrowing of the spinal canal.
• Ligamentous Hypertrophy: Thickening of the ligamentum flavum.
• Tumors: Intradural or extradural tumors.
• Trauma: Fractures or dislocations.

The compression leads to ischemia and neuronal dysfunction within the spinal cord, resulting in a variety of symptoms, including:

• Neck pain and stiffness
• Upper and lower extremity weakness
• Numbness, tingling, and sensory loss
• Loss of fine motor skills
• Bowel and bladder dysfunction (in severe cases)
• Gait disturbances (e.g., wide-based gait, spasticity)

Common Special Tests

These tests are used to help assess the presence of cervical myelopathy. Positive findings require correlation with clinical findings and imaging.

• Spurling's Test: Axial compression with neck extension and lateral flexion reproduces radicular symptoms. Suggests nerve root impingement, which may be present with myelopathy.
• Lhermitte's Sign: Electrical sensation down the spine and into the limbs with neck flexion. Suggests spinal cord involvement.
• Hoffman's Reflex: Flicking the distal phalanx of the middle finger causes flexion and adduction of the thumb. Suggests upper motor neuron lesion.
• Babinski Test: Stroking the lateral plantar surface of the foot causes dorsiflexion of the great toe and fanning of the other toes. Suggests upper motor neuron lesion.
• Inverted Supinator Sign (or Brachioradialis Reflex): Tapping the brachioradialis tendon elicits finger flexion rather than forearm supination. Suggests upper motor neuron lesion above the level of the brachioradialis reflex (C5-C6).
• Gait Assessment: Observe for wide-based gait, spasticity, and unsteadiness.

Phase I: Protection (Acute Phase - 0-4 weeks post-op or onset of symptoms)

Goals: Reduce pain and inflammation, protect the healing tissues, and prevent further neurological deterioration. If post-operative, follow physician's specific post-operative precautions.

• Pain Management:
  • Rest and immobilization (e.g., cervical collar) as prescribed by the physician.
  • Modalities: Ice, heat (as tolerated), TENS.
  • Gentle soft tissue mobilization to surrounding muscles (e.g., trapezius, levator scapulae).
  • Education on proper posture and body mechanics.
• Range of Motion (ROM):
  • Gentle active assisted ROM (AAROM) exercises within pain-free limits. Focus on cervical flexion, extension, lateral flexion, and rotation.
  • Scapular retraction and protraction exercises.
• Neuromuscular Re-education:
  • Isometric neck exercises in neutral position (flexion, extension, lateral flexion, rotation) to activate neck musculature without stressing the spinal cord.
  • Gentle core activation exercises (e.g., transverse abdominis activation).
  • Upper extremity proprioceptive exercises (e.g., joint position sense training).
• Patient Education:
  • Educate the patient on proper posture, body mechanics, and activity modification.
  • Provide instruction on wearing and caring for a cervical collar if prescribed.
  • Educate on signs and symptoms of neurological deterioration and when to seek medical attention.

Phase II: Loading (Subacute Phase - 4-12 weeks)

Goals: Improve ROM, strength, and endurance of neck and shoulder girdle musculature. Restore functional mobility.

• Range of Motion (ROM):
  • Progress to active ROM (AROM) exercises for the cervical spine and upper extremities.
  • Include stretching exercises to address any muscle tightness.
• Strengthening:
  • Progress isometric exercises to resisted neck exercises using therabands or light weights. Focus on all planes of motion.
  • Scapular stabilization exercises (e.g., rows, shoulder external rotation).
  • Upper extremity strengthening exercises (e.g., bicep curls, tricep extensions).
  • Core strengthening exercises (e.g., planks, bird dogs).
• Proprioception and Balance:
  • Progress proprioceptive exercises (e.g., wobble board exercises, single-leg stance with eyes closed).
  • Balance training exercises to improve stability and coordination.
• Aerobic Conditioning:
  • Initiate low-impact aerobic exercises (e.g., walking, cycling) to improve cardiovascular fitness.

Phase III: Return to Function (Chronic Phase - 12+ weeks)

Goals: Maximize functional abilities, return to pre-injury activity level, and prevent recurrence.

• Strengthening:
  • Progress strengthening exercises to functional activities (e.g., lifting, carrying).
  • Include sport-specific or work-related activities as appropriate.
  • Plyometric exercises (if appropriate and pain-free).
• Endurance:
  • Increase the duration and intensity of aerobic exercises.
  • Include endurance exercises for the neck and shoulder girdle (e.g., sustained postural exercises).
• Functional Training:
  • Simulate activities that the patient needs to perform at work or in daily life.
  • Address any remaining functional limitations.
• Patient Education:
  • Reinforce proper posture and body mechanics.
  • Provide strategies for preventing recurrence.
  • Encourage continued participation in a home exercise program.

Discharge Criteria:

• Achievement of functional goals
• Pain is well-controlled
• Adequate strength and endurance
• Demonstrates proper posture and body mechanics
• Independent with a home exercise program

This protocol is a guideline and should be adapted based on the individual patient's needs and progress. Close monitoring and communication with the patient and physician are essential for optimal outcomes.