Post-Fusion Cervical Rehabilitation Protocol

This rehabilitation protocol is a guideline for physical therapists managing patients following cervical fusion surgery. It is crucial to individualize the protocol based on the patient's specific surgical procedure, surgeon's recommendations, bone healing progress (as determined by imaging), comorbidities, and individual response to treatment. Constant communication with the surgeon is paramount throughout the rehabilitation process.

Pathophysiology

Cervical fusion is a surgical procedure performed to stabilize the cervical spine. It involves joining two or more vertebrae together using bone graft material (autograft or allograft) and instrumentation (plates, screws) to promote bone growth and create a solid bony fusion. This is often performed to address conditions such as:

• Cervical spondylosis (degenerative changes in the cervical spine)
• Cervical stenosis (narrowing of the spinal canal)
• Herniated disc(s) with nerve compression
• Cervical instability (e.g., due to trauma or rheumatoid arthritis)
• Fractures or dislocations of the cervical spine
• Tumors in the cervical spine

Following surgery, the immediate goal is to protect the surgical site and allow for bone healing. This involves minimizing stress on the fusion site while addressing pain, inflammation, and muscle spasm. As healing progresses, the focus shifts to restoring range of motion, strength, and functional abilities. The timeline for each phase varies depending on the individual patient and the extent of the fusion.

Phase I: Protection (Weeks 0-6)

Goals:

• Protect the surgical site and promote bone healing.
• Reduce pain and inflammation.
• Minimize muscle spasm and guarding.
• Educate the patient on proper posture and body mechanics.

Interventions:

• Patient Education:
  • Cervical collar use (as prescribed by the surgeon). Emphasize proper donning and doffing techniques.
  • Log roll technique for bed mobility.
  • Avoidance of excessive cervical flexion, extension, and rotation.
  • Proper posture during sitting, standing, and walking.
  • Activity modification to avoid heavy lifting (typically >5-10 lbs), repetitive movements, and prolonged static positions.
• Pain and Inflammation Management:
  • Ice or heat application (as appropriate and tolerated).
  • Gentle massage to surrounding muscles (e.g., upper trapezius, levator scapulae) to reduce spasm.
  • Transcutaneous Electrical Nerve Stimulation (TENS) for pain relief (if indicated).
• Gentle Range of Motion (ROM):
  • Scapular retractions and protractions.
  • Shoulder pendulum exercises.
  • Gentle cervical isometrics (flexion, extension, lateral flexion, rotation) – ensuring no pain or instability. Emphasis is on low-intensity and controlled movements.
• Breathing Exercises: Diaphragmatic breathing to promote relaxation and improve oxygenation.

Precautions:

• Strict adherence to surgeon's instructions regarding collar use and activity restrictions.
• Avoidance of any activities that cause pain or instability.
• Monitor for signs of infection (e.g., increased pain, redness, swelling, drainage).
• Avoid strenuous activity.

Phase II: Loading (Weeks 6-12)

Goals:

• Gradually increase cervical range of motion.
• Improve cervical muscle strength and endurance.
• Enhance posture and body mechanics.
• Begin light functional activities.

Interventions:

• Range of Motion:
  • Progressive cervical ROM exercises (flexion, extension, lateral flexion, rotation) – starting with active assisted range of motion (AAROM) and progressing to active range of motion (AROM).
  • Chin tucks.
  • Upper trapezius and levator scapulae stretches.
• Strengthening:
  • Progressive cervical isometrics (flexion, extension, lateral flexion, rotation) – gradually increasing the intensity and duration of holds.
  • Cervical dynamic exercises with light resistance (e.g., theraband, light weights) – focusing on controlled movements.
  • Scapular stabilization exercises (e.g., rows, scapular squeezes).
  • Postural strengthening exercises (e.g., chin tucks, thoracic extension exercises).
• Proprioception and Balance:
  • Balance exercises (e.g., tandem stance, single leg stance) – progressing as tolerated.
  • Cervical proprioceptive exercises (e.g., eye tracking, head repositioning).
• Ergonomics:
  • Workplace assessment and modifications to promote optimal posture and body mechanics.
  • Education on proper lifting techniques.

Precautions:

• Monitor for any signs of instability or pain exacerbation.
• Avoid excessive loading of the cervical spine.
• Progress exercises gradually, based on patient tolerance.

Phase III: Return to Function (Weeks 12+)

Goals:

• Restore full cervical range of motion and strength.
• Improve functional abilities and return to pre-operative activity levels.
• Maintain optimal posture and body mechanics.
• Prevent recurrence of symptoms.

Interventions:

• Advanced Strengthening:
  • Progressive resistance exercises with heavier weights or theraband.
  • Functional exercises that mimic activities of daily living (ADLs) and recreational activities.
  • Core stabilization exercises.
• Endurance Training:
  • Gradual increase in the duration and intensity of exercises to improve muscle endurance.
  • Cardiovascular exercise (e.g., walking, cycling) to improve overall fitness.
• Sport-Specific Training (if applicable):
  • Gradual return to sport-specific activities, with a focus on proper technique and body mechanics.
• Maintenance Program:
  • Establish a home exercise program to maintain gains in ROM, strength, and endurance.
  • Continue to emphasize proper posture and body mechanics.

Precautions:

• Avoid activities that cause pain or instability.
• Monitor for recurrence of symptoms and modify activities accordingly.
• Encourage patient to maintain a healthy lifestyle, including regular exercise and a balanced diet.

Common Special Tests

• Spurling's Test: Assess for nerve root compression.
• Distraction Test: Assess for relief of nerve root compression.
• ULTT (Upper Limb Tension Tests): Assess for neural tension.
• Cervical Flexion-Rotation Test (FRT): Assess for upper cervical joint dysfunction (C0-C1, C1-C2).

Disclaimer: This protocol is a general guideline and should be adapted to the individual patient's needs and surgeon's recommendations. Regular communication with the surgeon is essential throughout the rehabilitation process.