Physiotherapy History Assessment

Relevant history

• Neuropathic cervical/upper-limb symptoms for approximately 3-4 months before surgery.
• C5-C6 discectomy, osteophyte decompression, cage with bone graft, and anterior screw fixation were performed without documented perioperative complication.
• Postoperative radiograph shows C5-C6 anterior fixation and implant in situ.
• At discharge: afebrile, hemodynamically stable, pain controlled, wound dry, and ambulatory.
• Cervical collar was applied and is specifically mandated in the discharge instructions.
• No documented diabetes, prior medical illness, previous surgery, or weight-bearing restriction.
• Preoperative cardiac function is preserved: LVEF 60%, with grade-I LV diastolic dysfunction.
• Laboratory results do not show renal, liver, electrolyte, anemia, or platelet abnormalities relevant to routine rehabilitation.

Physiotherapy problem list

1. Recent C5-C6 fusion requiring protection while bony union develops.
2. Potential residual cervical myelopathy-related deficits:
   • hand dexterity impairment
   • altered balance or gait
   • upper-limb weakness, paresthesia, or neuropathic pain
   • reduced proprioception and coordination
3. Postoperative pain, guarded posture, and reduced activity tolerance.
4. Risk of deconditioning due to reduced physical activity.
5. Need for safe ADL, transfer, walking, sleeping, and ergonomics training.
6. Risk of shoulder and scapulothoracic stiffness if movement is excessively avoided.

Safety Rules and Surgeon Clearance

Stop exercise and obtain urgent medical assessment if there is:

• New or worsening arm/leg weakness, clumsiness, imbalance, falls, numbness, bowel or bladder disturbance, or electric-shock sensation with neck movement.
• Increasing neck or arm pain not settling with rest/medication.
• Fever, worsening wound redness, warmth, swelling, drainage, wound opening, or persistent severe headache.
• New swallowing difficulty, hoarseness that worsens, neck swelling, shortness of breath, chest pain, fainting, or confusion.
• New calf swelling/pain or sudden breathlessness.

Initial Physiotherapy Evaluation

Subjective assessment

• Neck pain at rest, during walking, sitting, transfers, and sleep using NPRS 0-10.
• Distribution and severity of arm pain, numbness, tingling, burning, or heaviness.
• Weakness, dropping objects, handwriting/buttoning difficulty, gait instability, falls, or lower-limb stiffness.
• Swallowing, voice, breathing, fever, wound symptoms, dizziness, and medication adverse effects.
• Usual work demands, computer/mobile use, driving requirements, lifting demands, exercise, tobacco use, and home support.
• Sleep position and tolerance of collar.

Objective assessment

• Vitals: BP, pulse, SpO₂ if indicated, exertional symptoms.
• Wound appearance only if clinically appropriate and within local scope.
• Collar fit, skin pressure areas, ability to don/doff only as prescribed.
• Posture: thoracic kyphosis, scapular position, guarded upper trapezius activity.
• Neurological screen:
  • upper-limb myotomes
  • light touch in C5-T1 distribution
  • grip strength only if it does not provoke symptoms
  • hand dexterity, for example 9-hole peg test where available
  • reflexes and pathological reflexes if within clinician scope
• Gait, turns, stair safety, tandem stance or supported balance tasks.
• Shoulder, elbow, wrist, and hand ROM with the neck kept neutral.
• Functional status: bed mobility, sit-to-stand, dressing, footwear, reaching, walking tolerance.
• Baseline outcomes:
  • Neck Disability Index
  • Numeric Pain Rating Scale
  • Patient-Specific Functional Scale
  • 10-Metre Walk Test or Timed Up and Go if balance/gait is affected

Staged Physiotherapy Protocol

Phase 1: Protection and early mobility

Postoperative day 1 to week 2

Goals

• Protect fusion and incision.
• Control pain and swelling.
• Maintain safe walking and independence with basic ADLs.
• Prevent deconditioning without loading the neck.
• Identify neurological deterioration early.

Collar and activity

• Wear the collar exactly as prescribed, including during walking and transfers if instructed.
• Avoid driving unless the surgeon has cleared it. Driving in a collar is generally unsafe because visual turning is restricted.
• Avoid tobacco/nicotine exposure because it can impair fusion healing.
• Avoid lifting more than 2-5 kg, pushing, pulling, overhead reaching, forceful housework, vacuuming, gym exercise, running, cycling on uneven surfaces, and contact activity unless the surgeon specifically permits otherwise.
• Avoid prolonged sitting. Change position every 20-30 minutes.
• Use a chair with back support. Keep the phone, screen, and reading material at eye level.

Exercises

Education

• Bed mobility: log-roll to turn, then push up with the arms while maintaining a neutral neck.
• Picking up objects: bend knees and hips, keep object close to the body, avoid bending/twisting the neck.
• Sleeping: use a firm, comfortable pillow arrangement that keeps the neck neutral. Avoid prone sleeping.
• Avoid heat directly over the incision. Ice packs may be used around the upper trapezius/shoulder region with skin protection, but not over the incision unless approved.

Do not perform in Phase 1

• Cervical ROM exercises.
• Chin tucks if these cause neck movement, pain, or are not cleared.
• Cervical isometrics.
• Manual therapy or mobilization to the cervical spine.
• Traction, manipulation, dry needling near the surgical region.
• Resistance-band upper-body exercises, planks, push-ups, sit-ups, or overhead activity.

Phase 2: Early healing and functional conditioning

Weeks 2-6

Goals

• Progress walking endurance.
• Improve posture and scapular control without stressing fusion.
• Restore safe shoulder, arm, hand, and lower-limb function.
• Improve balance and confidence in mobility.
• Remain within lifting and collar restrictions.

Treatment

Manual therapy

• May use gentle soft-tissue techniques to shoulder girdle, pectorals, and thoracic muscles only if the incision is fully healed and the treating clinician avoids stress on the surgical site.
• No cervical joint mobilization, traction, or thrust manipulation.

Progression conditions

• pain is stable or improving,
• no neurological deterioration occurs,
• gait/balance is safe,
• wound is healed,
• collar changes and lifting progression are approved by the surgeon.

Phase 3: Controlled mobility and strengthening

Weeks 6-12

Goals

• Gradually restore comfortable cervical mobility if cleared.
• Improve deep neck flexor activation and cervicoscapular endurance.
• Improve thoracic mobility, shoulder function, balance, and work capacity.
• Increase tolerance for routine household and desk activities.

Exercises

Cervical exercises

1. Gentle cervical active ROM in pain-free mid-range: flexion, extension, side-bending, and rotation.
2. Start with 5 repetitions in each direction, once daily.
3. Progress to 10 repetitions, 1-2 times/day if symptoms remain stable.
4. Do not force end range or use sustained stretching.
5. Begin low-load deep neck flexor activation only when the therapist confirms good control and the surgeon allows it.

Phase 4: Return to full function

From 12 weeks onward

Goals

• Restore work and household capacity.
• Build whole-body strength and aerobic fitness.
• Improve cervical and scapulothoracic endurance.
• Return safely to recreational exercise and, later, higher-demand work if approved.

Program

• Aerobic conditioning: walking, stationary cycle, elliptical, or swimming only after wound healing and surgeon approval.
• Progressive resistance training for legs, hips, trunk, and upper limbs while avoiding loaded end-range cervical positions.
• Gradual scapular and postural endurance training.
• Functional lifting practice:
  • keep load close to trunk
  • use hip/knee bend
  • avoid twisting while carrying
  • progress load gradually under therapist guidance
• Work conditioning for job-specific tasks, particularly if work involves lifting, overhead tasks, vibration exposure, prolonged driving, or sustained forward-head posture.

Suggested Follow-up Schedule

Measurable rehabilitation targets

• Independent and safe bed mobility, dressing, transfers, and walking.
• Walking tolerance of 30 minutes without symptom flare.
• Neck Disability Index improving from baseline.
• Stable or improving hand strength/dexterity and gait.
• Pain generally no more than 2-3/10 during routine activities.
• No wound, airway, neurological, or systemic warning signs.
• Independent long-term home program with correct posture and lifting mechanics.