Cervical Fusion Protocol

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1 REHABILITATION DEPARTMENT Cervical Fusion Protocol The following protocol for physical therapy rehabilitation was designed based on the typical patient seen at the Texas Back Institute for the procedure of cervical fusion. Each physician has his/her own specific guidelines for the rehabilitation process. Therefore, this protocol was designed to encompass both the physician s and therapist s philosophies. Deviations from the protocol are dependent on prior level of function, general health of the patient, equipment available, patient goals, specific orders written on the prescription, and others. It is the treating therapist s responsibility along with the referring physician s guidance to determine the actual progression of the patient within the protocol guidelines. Three important concepts of the progression of physical therapy cervical fusion protocol are scapular stability, cervical stability, and functional activity. It is important that the patient follow the limitations set forth from the physician such as a limitation in lifting of less than five pounds during the first two weeks and then a gradual progression toward functional activities that do not place excessive stress to the cervical region. In most cases patients will exhibit a functional cervical range of motion which is encouraged within a pain free range. Once fusion has occurred, the therapist may facilitate cervical ROM within a pain free range. Hyperactivity of the upper traps along with an imbalance of decreased lower trap strength must be addressed throughout the treatment process. Exercises should be designed to increase scapular and cervical stability within a safe limit. Once proper stabilization can be demonstrated by the patient without cueing, a progression of exercises to further develop and improve stabilization (coordination) should be considered. Proper stabilization must be achieved with each attempted exercise prior to progressing to moderate/advanced stabilization exercises. Many exercises are described in the protocol, however, the list is not exhaustive and other options may be incorporated as needed. The treating therapist will use his/her professional judgment guided by the patient s response and mechanical basis for achieving proper stabilization to determine when proper progression of exercises can occur. The following clinical observations require a consultation with the referring/consulting physician: 1. Failure of incision to close or significant redness, swelling or pain in the area of incision. 2. Unexpectedly high self-reports of pain in comparison to presurgical state. 3. Failure to meet progress milestones according to protocol guidelines as may be modified by clinical judgment with consideration given to previous presurgical state and typical progression of patients during rehabilitation. 4. Evidence of acute exacerbation of symptoms: significant increase of pain, sudden increase of radicular symptoms, and/or sudden loss of strength/ sensation/ reflexes. 5. Development of new unexpected symptoms during the course of rehabilitation. This is for information only and is not intended to substitute for sound clinical and professional knowledge.

2 Cervical Fusion General Considerations: Decrease Swelling Prevent Stiffness Improve Stabilization Increase Activity Tolerance Precautions With Anterior Cervical Fusion avoid extension With Posterior Cervical Fusion avoid flexion A.R.O.M. is patient dependent and will be based on Physician preference and the level and number of fusions. PHASE CONSIDERATIONS TREATMENTS GOALS I. Pre- P.T. Increase tissue tolerance to activity Home Exercise Program Decrease inflammation Per hospital discharge Increase cervical isometric tolerance Cardiovascular Exercises Encourage wound healing Bike Walking Wound Healing and Protection 0-3 weeks II. Initiation of P.T. Basic Stabilization, Flexibility, Body Mechanics, and Activity Tolerance 3-6 weeks 2-3 sessions/week III. Advanced P.T. Strength, Balance activities, and Cardiovascular training 6 10 weeks 2-3 sessions/week IV. Functional Rehabilitation Recreational Activities, Return to Work, Advanced Stabilization, Independent Program Teach scar mobilization Stabilization with U/E exercises Posture Body Mechanics o ADL discussion Advance Isometrics Restricted to 5 lbs. max with free weights No overhead activity Positional tolerance Return to work investigation Body mechanics, posture emphasis with exercises, postural drills Increased upper extremity strength and stabilization (primary scapular) Spinal stabilization (all levels) ADL review for problem areas Soft tissue mobilization Return to work assessment Cervical Mobility Progress to independent program Restrictions limited to safety issues Encourage cardiovascular, strength, and flexibility training Progress to pre-morbid activities Review postural drills Cervical Isometrics Shoulder Shrugs Shoulder Rolls Scapular Mobilization and Stabilization Thoracic Mobilization Neuromuscular Re-education Abdominal Exercises (watch position of the c-spine) Basic Core Stabilization (Lumbar)* Incline push up Shoulder Shrugs and Rolls ( 2-5 lbs.) Chest Press Seated Rows (Trunk Stabilized) Rhythmic Stabilization of upper quarter Gentle MFR and O/A work UBE Gentle AROM to c-spine (see precautions) Consider FCE at end of phase (physician dependent) Independent program with integration of posture, strength, flexibility, and lifting considerations Review of ergonomics FCE / Return to Work Program if appropriate Independent HEP Activity Tolerance o Light resistance training/mat exercise= 15 minutes o Cardiovascular = 20 minutes Weaned to soft collar per physician orders Functional ADL for hygiene MMT 4/5 U/E except overhead Prone dorsal cervical glide 15 sec. Sidelying head hold 15 sec. Modified Plank 10 sec. Demonstrate proper scapulo-humeral rhythm Sitting/Standing posture 30+ min. Cardiovascular activity = 30 min. Light resistance training/mat exercise = 20 min MMT 5/5 U/E Prone dorsal cervical glide 30 sec. Sidelying head hold 30 sec. Modified Plank 30 sec. Continued cardiovascular activity = min 30 min. Continued resistance training/mat exercise = minimum of 30 min. MMT 5/5 U/E Prone dorsal cervical glide 1 min. Sidelying head hold 1 min. Modified Plank 1 min. Independent with all Exercises and home/gym program Resumption of recreational activity Demonstrate proper body mechanics and posture 10 weeks +

3 CERVICAL FUSION PROTOCOL EXERCISE EXAMPLES ISOMETRIC CERVICAL EXTENSION With head in neutral position, place hand behind head Attempt to bend neck backwards, resisting the movement with your hand Purpose: strengthen neck extensor muscles ISOMETRIC CERVICAL ROTATION With head in neutral position, place hand on side of forehead. Attempt to turn head to side (rotation), resisting the movement with your hand. Purpose: strengthen the muscles responsible for rotation in the neck ISOMETRIC CERVICAL FLEXION With head in neutral position, place hand on forehead Attempt to bend the head forward, but resist the movement with your hand Purpose: strengthen the neck flexors ISOMETRIC CERVICAL SIDE BENDING With head in neutral position, place hand on side of head Attempt to bend head sideways, resisting the movement with your hand Purpose: strengthen the muscles responsible for side bending your neck CERVICAL RETRACTION (CHIN TUCK) PRONE Lay face down Tuck chin and hold 1-2 seconds Return to start position CERVICAL SIDEBENDING SIDELYING Lie on right side Looking straight ahead bend neck sideways, moving ear toward left shoulder Return to start position Repeat lying on left side Move in pain free range MODIFIED DORSAL GLIDE Lie on stomach in prone position propped on elbows. Retract cervical spine and scapula to neutral position and hold. Relax to start position and repeat. DORSAL GLIDE WITH SCAP RETRACTION Lie on stomach propped on elbows. Retract cervical spine to neutral; then retract scapula and elbows hold. Relax to start position and repeat. MODIFIED PUSHUP Lie on stomach with elbows bent and hands on the floor next to your shoulders. Maintaining neutral spine, push your torso up, bending at the knees. Return to start position

4 ANTERIOR/POSTERIOR CERVICAL FUSION HOME EXERCISE PROGRAM Begin these exercises your first full day home and progress gradually as tolerated. Do 5-10 repetitions of each exercise three times a day in bed. It is important to do these exercises in order to promote healing, prevent blood clots, and improve respiratory function. Quad sets, Hams sets, glut sets, and ankle pumps learned in the hospital, perform every hour Shoulder abduction, flexion, and rotation Active hip flexion, and active hip rotation Walking walk for short distances at first, twice daily, at a comfortable pace. Choose a safe, paved area. Gradually increase to one half mile in the morning and one half mile in the evening by 1-2 months) or start out 5 minutes in one direction and 5 minutes back, gradually increase time as tolerated up to 45 minutes total. Avoid bending head forward if you had a posterior fusion (incision on back of neck). Avoid bending head backward if you had an anterior fusion (incision on front or side of neck) Be attentive to your body s painful warning signals which may indicate over activity or undue stress. Discontinue any of the above exercises that either: Cause persistent pain in the neck, shoulders, arms or hands during or following the activity, Or Cause an abnormal increase in morning pain or stiffness (muscle soreness is okay, pain similar to that prior to surgery is not okay). These home exercises were designed for your surgical procedure in order to increase your strength, endurance, and mobility within an ample time period. Your outpatient physical therapist will progress you through more advanced exercises when appropriate, and guide you safely back to a more normal activity level. The outpatient therapy is an essential part of your rehabilitation. Driving: None for the entire time patient is in the Aspen or Philadelphia collar. Consult doctor before driving. In addition to the above precautions, patients should not drive cars with standard transmissions (stick shifts) without consulting physician. Lifting: 5 lb. for the first two weeks, then progress slowly. Do not lift above shoulder level. No overhead lifting or activity. Sitting: Sit as tolerated getting up every 30 minutes to adjust posture. Avoid slouching. Sex: Wait two weeks. Use the least exerting and most comfortable positions. Tub Baths/Shower: If hip graft is present, none for 1 month because of posture and submersing the incision. Shower only in the Philadelphia collar (peach colored foam rubber). Household Chores: None for 3-6 weeks, or as approved by your physician. Progress slowly as you begin. Consult your outpatient physical therapist for proper body mechanics. Yard Work: Consult physician before performing yard work. Observe proper body mechanics and lifting limit. Braces: The Philadelphia collar (peach colored foam rubber) is generally fitted directly after surgery. Aspen or Miami collars may be fitted later for comfort. Shower in the Philadelphia collar.

5 ANTERIOR/POSTERIOR CERVICAL FUSION HOME EXERCISE PROGRAM Perform these exercises hourly: HAMSTRING SETS: Slightly bend your knee, press your heel down into the bed and tighten the muscle on the back of your thigh. Hold for 5 seconds. Relax, then repeat 5 times. As tolerated, bend knee further, keeping foot on bed. QUAD SETS: With a straight leg press your knee down into the bed and tighten the muscle on the front of your thigh. Hold for 5 seconds. Relax, then repeat 5 times. GLUT SETS: Squeeze your buttocks together gently. Hold for 5 seconds. Relax. Then repeat 5 times. Avoid arching your back ANKLE PUMPS: Move foot/toes toward you and then down point foot away ---bending at the ankle. Repeat 5 times. Perform these exercises 2-3 times a day UE ISOMETRIC EXERCISE: Lie on your back with arms extended at your side. Press your arms into the bed. Squeeze shoulder blades together while pressing. Do not arch your back. Hold 5 seconds. Repeat. SHOULDER ABDUCTION: Keeping elbows straight, bring arms out to side and all the way overhead or as far as tolerated. SHOULDER ROTATION: With elbows bent and at shoulder level, bring back of hands back to touch bed then forward to touch with palms. HIP FLEXION: Bend at your hip pulling your knee toward your chest, do not bend more than 90 degrees at your hip. Hold for a count of 5 and slowly lower your leg. HIP ROTATION: Lie on your back with your legs straight. Tighten stomach and roll knees and toes inward then outward. Repeat.

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