Download A rehabilitation programme after C1

86
EEXOT
Volume 63, (2): 86-88, 2012
A rehabilitation programme after C1-C2 fusion
GRAMMATICOS GT1, ΜΑRΚΑΤΟS Κ2, ΚΑSΕΤΑ ΜΚ3
KONSTANTOPOULEIO HOSPITAL, 2ND ORTHOPAEDICS DEPARTMENT OF THE UNIVERSITY OF ATHENS
Physiotherapist
1
2
Resident in Orthopaedics in the 2nd Orthopaedics Department of the University of Athens
Orthopaedic surgeon, 2nd Orthopaedics Department of the University of Athens
3
ABSTRACT
ANATOMY
The purpose of this article is the presentation of a
rehabilitation protocol after fusion of the cervical spine
in the C1-C2 level. The distinctive anatomy and increased
range of motion of the cervical spine and its hence increased
sensitivity make rehabilitation difficult and demand total
co-operation of the patient.
Emphasis is given in the rehabilitation process in relation to
the regional anatomy (muscles, ligaments) and mobilization
in stages and muscular strengthening.
Finally it is clarified that this is not the only protocol of
spine rehabilitation after C1-C2 fusion. Nevertheless it is
considered safe and effective in increasing mobility and
pain management.
The cervical spine is articulated to the occipital bone in
the atlantooccipital joint. The suboccipital muscles that
stabilise and define its movement are:
1) Superior oblique: C1 transverse process laterally to
occiput medially.
2) Inferior oblique: C1 transverse process laterally to spinous
process of C2 medially.
3) Rectus capitis posterior major: spinous process of C2
up to base of occiput.
4) Rectus capitis posterior minor: posterior tubercle of C1
up to base of occiput.
5) Semispinalis capitis: transverse processes of cervical
vertebrae to nuchal ligament and occipital bone;
superficial to suboccipital muscles.
6) Longissimus capitus: similar to semispinalis but runs and
attaches more laterally to the occiput.
Cervical vertebrae are confined and supported by a
complex ligamentous system formed by:
1) The anterior longitudinal ligament covers anterior
vertebral bodies and limits extension.
2) The posterior longitudinal ligament covers posterior
vertebral bodies and limits flexion.
3) The interspinous and supraspinous ligaments run between
adjacent spinous processes and form the ligamentum
nuchae.
4) The ligamentum nuchae across the posterior surface of the
spinous canal and between the arches of neighbouring
vertebrae.
The posterior view of cervical spine muscles shows that
the spinous process of C2 has a centrical position with
the muscles radiating towards all directions. The upper
INTRODUCTION
The cervical Spine is formed by two distinctive components
anatomically and functionally:
-The upper part which is formed by atlas and axis. These
two vertebrae are connected to each other and to the
occipital bone through a chain of joints with three axis
and three degrees of freedom. Between these vertebrae
there is no intervertebral disc.
-The lower part which starts beneath axis and reaches
the upper surface of T1. The joints of the lower part
have two axis of movement: flexion-extension and lateral
1
flexion-rotation .
Mailing Address:
Markatos Konstantinos
e-mail: [email protected]
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A REHABILITATION PROGRAMME AFTER C1-C2 FUSION
Phase 1.
Phase 2.
cervical spine muscles beneath C2 have a distinct specialized
formation in contrast to the lower cervical spine where
muscles are continuous and overlapping. This explains why
lower cervical spine is mobilized as one unit with each
muscle moving different segments, while upper cervical
spine can perform distinct motions in each segment, like
2
rotational motion in C1-C2 level .
patient is instructed what to avoid like: sweeping, gardening,
making beds, weight lifting, infant lifting etc.
Education of the small stabilizing muscles (Local stability
system). Rectus capitis posterior major and minor, superior
and inferior oblique.
Walking is recommended as aerobic exercise. Two to
four short walks are more appropriate than one longer
distance.
After the first six weeks the patient is able to exercise on
another low resistance level: static bicycle, electric corridor
running, walking in the water are mostly recommended.
Labour workers are not to return to employment yet,
but those working in an office can work if instructed in
their working surroundings and provided that they make
often short intervals at work.
All patients should by the end of the first year after the
4,5
operation be able to carry weight of 10kgr .
REHABILITATION PROGRAM
The rehabilitation program after C1-C2 fusion is divided
into three phases.
PHASE 1-1st-10th postoperative day.
PURPOSE:
Protection of the operation site, pain management,
independence in daily activities (use of special pillow).
MEANS:
- Patient education and adaption in the daily house
activities.
- Patient education for proper bed resting position and
movement control (low range of motion, progressively
increased).
Usually voice hoarseness and difficulty in shallowing
are presented. In that case the assistance of a speech
3
therapist is in order .
PHASE 2-2nd-12th week.
PURPOSE:
Protection of the operation site, pain management,
increase in the energetic range of motion, motion is
approaching normal levels, increase of physical activity
(aerobic exercise).
MEANS:
Ergonomics education. The patient is instructed not to
lift weight more than 1-2kgr and to avoid sudden neck
movement for the next 6 weeks.
During the first 6 weeks secured motion is in order. The
PHASE 3-Starts by the end of the 3rd month.
Therapeutic exercise: energetic to increase cervical spine
range of motion and to increase muscular strength (this
requires extra caution), isometric exercises, isotonic exercises
(with a rubber rope).
These exercises can be combined with other therapeutic
3
means: warm patches, TENS, manual therapy, etc .
The proposed exercising program is always correlated
to movement ability, age, psycological status and patient
discipline.
It is important to understand that after C1-2 what cannot
exist is motion in this level.Therefore the lower vertebrae
of the cervical spine carry more stress in flexion, extension
and rotation of the neck.
Special attention to the thoracic spine is in order because
it needs individual mobilization.
Exercising to increase range of motion should be mild
and should lead in time by means of repetition in decreased
muscular spasm:
- Isometric exercises: 3*10 repetitions with holding of 5
seconds.
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E.E.X.O.T., Volume 63, Number 2, 2012
Phase 3.
- Education of deep stabilizing system. The use of a stabilizer
is in order.
- Ergonomics in all positions in order not to increase tension
in the operating site.
The result of the physiotherapy program described
above will lead to a gradual decrease of muscle spasm in
the cervical spine, pain management will be achieved and
6
a gradual increase in muscle elasticity will be presented .
Special attention should be paid in muscular strengthening
around the scapulla. These muscular groups should be
stabilized and strengthened in order to achieve better
posture and decreased tension in the cervical spine: 4*1015 repetitions.
This is a complete rehabilitation program for the cervical
spine after C1-2 fusion. However in case of patient lack of
compliance one should re-educate the spine and decrease
the number of exercise repetitions always in correlation
5,7
to the operation site .
It should be emphasized that this is not the only program
of cervical spine rehabilitation after C1-C2 fusion. It is
merely a secure rehabilitation protocol which, if properly
executed, will lead in early and efficient mobilization of
the cervical spine with pain management and without
destruction of the operation site.
REFERENCES
1. KAPANDJI IA: The Physiology of the Joints. Paschalides Medical
Publications.
2. Penning L: Normal Movements of the Cervical Spine. Am. J.
Roentgenol. 1978: 130:317-326.
3. Brian C. Edwards. Manual of Combined Movements, 2ND
Edition.
4. Bhantagar M et al. Spinal Fusion & Rehabilitation.
5. Cherry C. Anterior cervical discectomy & fusion for cervical
disc disease. AORN 6. Journal. www.looksmart.com 2005.
7. Graig Liebenson. Rehabilitation of the Spine, 2nd edition.
8. Grieve 's Modern Manual Therapy 3rd edition. Elsevier.