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My prescription for physical therapy from my neurosurgeon. All I can read is “ROM (range of motion) & ????? of upper extremities, local modalities.” Comment below if you can manage to understand the ????? part!

After hours upon hours of doing those physical therapy exercises on my now-liberated neck, allow me to bask in the glory of my improvements!

I took photos of the range of motion (ROM) of my neck on Day 2, Week 6, and Week 11 after getting my neck brace off. Pardon the low quality of these images from Photo Booth… I didn’t want to bother setting up a tripod and everything. It took me a while to get these photos together, but they show my progress quite well, I promise!

Range of motion of the neck

Note that there are six primary directions of neck movement and all other movements are just combinations of these:

  • Extension (looking up)
  • Flexion (looking down)
  • Bilateral side rotation to the right (looking right)
  • Bilateral side rotation to the left (looking left)
  • Bilateral side flexion to the right (bending right)
  • Bilateral side flexion to the left (bending left)

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From Washington Ergonomics (1994)

Measurements for the maximum normal neck ROM vary across individuals, but range approximately from  80° to 90° for flexion, 70° for extension, 20° to 45° for lateral flexion, and up to 90° for rotation to both sides (Windle, 1980). In a study of 400 healthy people without neck issues, Swinkels et al. (2014) also demonstrated that neck mobility diminishes with age.

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Values in degrees

Permanent lack of movement?

Because I underwent ACDF (anterior cervical discectomy and fusion) surgery wherein three levels of my vertebrae were fused together, I know I will never obtain the normal ROM for my age of 27 (first column above). No movement occurs between the fused levels. Right from the get-go, my neurosurgeon told me to expect about a 20-30% loss of ROM in my neck as a result of the surgery.

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Levels C5, C6, and C7 fused by a metal plate and bone grafts

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The joints between the individual vertebrae of the neck allow the head to move forward, backward, and side to side.  By themselves, each of the disks between the vertebrae provides only a small amount of movement, but as a group the amount of movement potential is significant (Washington Ergonomics, 1994).

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neck-nerves-picture-237x300Movement in the cervical spine is complex. Movement in any range is not just the simple sum of equal motion from one vertebra to the next (Van Mameren et al., 1990). However, a great deal of motion is concentrated in specific areas. For example, 50% of rotation is controlled by the C1-C2 articulation (Namdari et al., 2015) – which is great for me given that the lower C5, C6, and C7 levels that I fractured don’t contribute very much to that movement anyway.

My neurosurgeon told me, however, that I may be most limited in side flexion as the C5 to C7 levels do contribute to that movement substantially. In addition, most of the movement in flexion and extension is controlled by the lower C3 to C7 vertebrae (Namdari et al., 2015). The substantial damage to the ligaments in my neck further complicates what ROM I can expect to regain through physical therapy. In a study by Wu et al. (2012) on 29 middle-aged patients (mean age of 49) who underwent three-level fusion surgery like me, all patients experienced a decreased ROM in all cardinal planes of movement (although in varying degrees). More conflicting information from different neurosurgeons here.

In short, I don’t really know what to expect in the long run. I will just continue doing my neck exercises until I see no further improvement in my ROM. From what I’ve read, the resulting ROM of a three-level fusion has proven to be functional enough for daily living.

My monthly improvements

I worked on getting all six directions as close as possible to the normal ROM as well as strengthening my neck muscles by patiently doing my physiotherapy exercises daily since Day 1. For some context, here are the other important activities that contributed to the recovery of my neck:

Day 1, December 4th Got my neck brace off, physio evaluation, started physio exercises
Day 1 quantitative measurement and photos below (photos also here)
Week 4, January 4th Went to new physio, started new physio exercises
Week 5, January 9th Started gentle Hatha yoga 1-2x/week
Week 5, January 12th Started strength training program 3x/week with kinesiologist (will write about this soon!)
Week 6 photos below
Week 6, January 18th Started hot yoga (Bikram and Vinyasa) 2-3x/week (also coming soon!); stopped gentle Hatha yoga
Week 10, February 17th Started swimming 2x/week (also coming soon!)
Week 10 photos below (I realized I put Week 11 in all of the photos but I don’t want to re-do them all again!)
Week 11, February 25th Physio evaluation for follow-up appointment with neurosurgeon
Week 11 quantitative measurements below

In each photo I was holding my neck as far as possible until I felt pain and/or resistance (active ROM). Feel free to click the photos to enlarge.

Extension

I didn’t experience much improvement here, mostly because I could already look up quite a ways right after my neck brace was removed (which was an utter shock to me). Nevertheless, I keep seeing more and more of the ceiling now! I believe it will be enough to look at the ceiling (the “back”) when I go back to working and mapping underground. I still need to build strength in my neck to be able to wear my hard hat with the cap lamp and ear muffs attached.

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From mining industry photographer James Hodgins

Day 1 approximation: 60% of normal ROM

Week 11 (nearly Month 3)approximation: 75% of normal ROM

Flexion

Only minor improvements here as well. Often, I hear some little cracking noises when I bend my neck down further (and sometimes it’s painful).

Day 1 approximation: 60% of normal ROM

Week 11 (nearly Month 3) approximation: 75% of normal ROM

Side rotation – left

I noticed a HUGE change here, which is evident from the photos. One day I doing my neck exercises and noticed that Hey, I can turn my head more! That was such a great feeling.

Day 1 approximation: 50% of normal ROM (look how pitiful the first photo is!!!)

Week 11 (nearly Month 3) approximation: 75% of normal ROM

Side rotation – right

It is not obvious in the photos, but my right side is more limited than the left. I feel most of my pain on this side too.

Day 1 approximation: 50% of normal ROM

Week 11 (nearly Month 3) approximation: 75% of normal ROM

I am pretty sure I can now re-enact this pose from our wedding:

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Right?!

Side flexion – left

I was extremely limited here at the start. It was like my head didn’t even move from the centre! I barely improved during my first month out of my neck brace, probably because I didn’t have any exercises to work on this direction at first. I am happy that I can bend my neck to the side further now!!! But I did endure a lot of pain in stretching my neck to get here.

Day 1 approximation: 30% of normal ROM

Week 11 (nearly Month 3) approximation: 65% of normal ROM

Side flexion – right

Same as above. It was painful getting here, but I’m glad I made it through.

Day 1 approximation: 30% of normal ROM

Week 11 (nearly Month 3) approximation: 65% of normal ROM

A flashback to my thin, fragile neck

Not only did have to increase my range of motion, I also had to regain the muscle mass I lost from wearing neck braces for seven and a half months!

For the first several weeks, I still rolled onto my side every time I got out of bed, as if I had a neck brace on. I still do that now, but I’m more comfortable with getting up from my back. My husband also says my neck seems to have gained most of its muscle now.

Neck Disability Index (NDI)

The Neck Disability Index (NDI) is a questionnaire used to understand how neck pain due to trauma affects one’s abilities to manage daily activities. Patients rate their degree of pain/discomfort while performing daily tasks. It is NOT a measure of the level of pain, but the level of self-rated disability.

The NDI consists of 10 items, each with a score up to 5, for a total score of 50. The lower the score, the less self-rated disability. Interpretation of a patient’s score:

  • 0 – 4 = No disability
  • 5 – 14 = Mild disability
  • 15 – 24 = Moderate disability
  • 25 – 34 = Severe disability
  • 35 or over = Complete disability

When I took the questionnaire with my occupational therapist three weeks ago (Week 11), I responded that I could not work nor drive at the time. Otherwise I have very little to no trouble performing my daily activities (personal care, lifting, reading, etc.). I scored 11/50 or 22% and was therefore considered to have a mild disability.

Feedback from my neurosurgeon

I had a follow-up appointment with my neurosurgeon around two weeks ago. It was the six-month mark following my surgery. He was just amazed with the improvements I have made in the three months after I got my neck brace removed.

This was our actual conversation:

Me: “So, my physio evaluated me and said that my range of motion was around 65 to 75%.” *moves neck around to show him*

Dr. J: *with a “Are you kidding me?” kind of look* “That’s amazing.”

He said that my current ROM was sufficient for daily living. He also allowed me to drive (more on that later!). As for working back at the mine, he told me I could try in June, three months from now.

Although my neurosurgeon told me that I can stop going to physiotherapist for soft tissue mobilization, I still need to do my neck exercises. He thought that the soft tissue massaging wasn’t going to be worthwhile anymore (especially now that I am paying for it on my own) and that the occasional vertebral manipulation my physiotherapist was doing (on my lower back, to apparently alleviate the stress higher up in my neck) was just BS. Whether that lower back manipulation (i.e., sudden cracking… eep) did help me, I will never know. I was always on the fence about it anyway, and at least I now have confirmation that I don’t need to go through that anymore. Unless my disability insurance tells me that they’re willing to cover my future physiotherapy appointments for soft tissue mobilization, I’m going to stop going to the physiotherapist and just carry on by myself. I honestly feel uneasy about it, but I can’t afford unnecessarily spending $68 twice a week for three more months.

As I left the fracture clinic where I saw my neurosurgeon, I overheard him talking to this middle-aged lady who fractured her ankle. She said that she didn’t go to a physiotherapist but did some exercises she found on the internet (like, two). When my neurosurgeon asked her if she did some strengthening exercises, she replied, “What’s that?”

I think I’m much better off.

What helped me

Aside from those boring yet invaluable neck exercises and neck mobilization from my physiotherapist, I engaged in other activities that involved moving my neck and upper body more. More on my exploits in yoga, strength training, and swimming next time!

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