Physical Therapy Following Anterior Cervical Discectomy and Fusion: A Study of Current Clinical Practice and Therapist Beliefs

Abstract

Background: Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical procedure. However, there is substantial debate regarding the role of physical therapy following this procedure. Therefore, we sought to determine current physical therapy practice following ACDF surgery, as well as determine physical therapists beliefs regarding rehabilitation following ACDF.
Methods: One hundred and eighty three licensed Physical Therapists were invited to participate in a descriptive internet based survey; a total of 53 (29%) completed the survey. Physical Therapists were assessed for their current practice, asked to rate the clinical usefulness of various treatment modalities, and indicate their recommendations regarding post-operative physical therapy for subjects following anterior discectomy and fusion. Results were then assessed for frequency distributions, with chi-square analysis for association between demographic data and practice recommendations.
Results: The results indicate that Physical Therapists believe patients achieve superior outcomes with the inclusion of post-operative physical therapy, with a low risk of harm. Specific treatments indicated as most useful included endurance exercise (60.4%), isometric strengthening (56.6%), and stretching (45.3%). Other treatment options are discussed in detail.
Conclusion: Physical Therapists identified specific activities that they felt were most appropriate for rehabilitation following ACDF surgery. These findings may help to direct both appropriate therapy prescription following ACDF, as well as future research.

Full text

Int J Physiother 2015; 2(2) Page | 399
1Brian T. Swanson
2Robin R. Leger
CORRESPONDING AUTHOR
1Brian T. Swanson
PT, DSc, FAAOMPT
Texas Woman’s University,
School of Physical Therapy,
Houston, TX, USA.
Int J Physiother. Vol 2(2), 399-406, April (2015) ISSN: 2348 - 8336
ABSTRACT
Background: Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical
procedure. However, there is substantial debate regarding the role of physical therapy following this
procedure. Therefore, we sought to determine current physical therapy practice following ACDF
surgery, as well as determine physical therapists beliefs regarding rehabilitation following ACDF.
Methods: One hundred and eighty three licensed Physical Therapists were invited to participate in a
descriptive internet based survey; a total of 53 (29%) completed the survey. Physical Therapists were
assessed for their current practice, asked to rate the clinical usefulness of various treatment modalities,
and indicate their recommendations regarding post-operative physical therapy for subjects following
anterior discectomy and fusion. Results were then assessed for frequency distributions, with chi-square
analysis for association between demographic data and practice recommendations.
Results: The results indicate that Physical Therapists believe patients achieve superior outcomes with
the inclusion of post-operative physical therapy, with a low risk of harm. Specific treatments indicated
as most useful included endurance exercise (60.4%), isometric strengthening (56.6%), and stretching
(45.3%). Other treatment options are discussed in detail.
Conclusion: Physical Therapists identified specific activities that they felt were most appropriate for
rehabilitation following ACDF surgery. These findings may help to direct both appropriate therapy
prescription following ACDF, as well as future research.
Keywords: Cervical spine surgery, ACDF, physical therapy, practice patterns, evidenced-based practice.
2 RN, MS, PhD
Associate Professor, Graduate School
of Nursing, Salem State University,
Salem, MA, USA.
Received 28th February 2015, revised 27th March 2015, accepted 31st March 2015
DOI: 10.15621/ijphy/2015/v2i2/65249
www.ijphy.org

Int J Physiother 2015; 2(2) Page | 400
INTRODUCTION
Anterior cervical decompression and fusion (ACDF)
has been shown to be successful in the
management of cervical disc disease.1 While there
is general agreement among both physicians and
physical therapists that patients undergoing
cervical spine surgery need regular follow up,
postsurgical rehabilitation recommendations
following cervical spine surgery have not been well
established. Physical therapy is commonly utilized
during both the pre and post-operative period, with
approximately 70% of surgeons regularly utilizing
physical therapy services, according to our previous
survey of the members of the North American Spine
Society.² Despite being frequently used, the effect
of rehabilitation following ACDF on patient
reported outcomes is unknown.
Few prospective studies have been published with
respect to outcomes and disability following ACDF.3
While generally successful in the treatment of
radicular symptoms, with over 75% reporting relief
at 2 years post-operatively,4-6 it is not uncommon
for patients to remain otherwise symptomatic.4
Peolsson et al 3prospectively evaluated a group of
patients undergoing ACDF and found only 5 of 34
(15%) patients were without complaints of neck
problems according to the Neck Disability Index
(NDI), pain scores, and general health measures at
1 year postoperatively. The prevalence of neck
related disability prompted the authors to conclude
that improved surgical techniques and
postoperative rehabilitation are greatly needed.
With an increase of greater than 200% in the
volume of cervical spine surgeries performed over
the last decade, evidence based practices for
cervical spine surgeries are becoming increasingly
more important.7 In the current climate of cost
reduction, utilization of rehabilitative services is
being examined closely, particularly in situations
where there is a lack of evidence regarding their
short and/or long term benefits. In particular, there
is little data available regarding the best physical
therapy practices in this post-operative population.
Therefore, to facilitate recommendations for
clinical trials or other critical studies regarding
postsurgical rehabilitation, we sought to determine
the current practice patterns of physical therapists
regarding postsurgical rehabilitation techniques
and recommendations following cervical spine
surgery.
Sample
Participants were recruited from two private
physical therapy practice groups (Select Medical
Corporation, New England region n=100, Physical
Therapy and Sports Medicine Centers of CT n=35),
and the membership of the Connecticut Physical
Therapy Associations Orthopedics and Manual
Therapy special interest group n= 48. Potential
subjects received an e-mail inviting them to
participate, which contained a link to the on-line
survey as well as information regarding the
deadline for completion. Participants were
informed that the survey would take approximately
10 minutes to complete and that the information
gathered for the study was confidential and
anonymous. Participants were sent two reminders
over a period of two months to aide in recruitment.
METHODS
The authors developed an internet based survey
similar to the survey conducted with the surgical
members of the North American Spine Society. 2
Subjects completed an internet based survey
consisting of 21 questions. The first portion of the
survey contained questions regarding demographic
and training characteristics, including fellowship or
residency training, length of the time since the
completion of training, specialization, type of
practice (academic, private practice, hospital,
multispecialty group, other), therapist age, and
yearly volume of cervical spine post-operative
rehabilitation procedures performed by the
individual therapist. The second part of the survey
contained questions pertaining to therapist beliefs
regarding rehabilitation following ACDF, and the
final section contained questions regarding the
frequency and duration of postsurgical
rehabilitation and specific intervention
recommendations following cervical spine surgery.
Prior to distribution of the survey, the tool was
reviewed by two independent practitioners, one a
spine surgeon, one a physical therapist with
orthopedic specialist certification for content
validation.
Responses were analyzed using uni-variate
statistical analyses, including frequencies of
responses for categorical variables. Frequency
distributions were created for all response variables
and bi-variate cross-tabulations were used for
comparisons of selected demographic variables
with selected practice variables. When appropriate,
original responses were collapsed into fewer
categories. Chi square tests were used to compare
associations between demographic variables and
practice-related responses. Finally, a Spearman rho
correlation was used to assess the relationship
between demographic variables and practice
recommendations. All calculations were completed
using SPSS Version 16 (IBM SPSS Statistics, Rel.
19.0.0. 2010. Chicago: SPSS Inc., an IBM Company).
An alpha-level of <0.05 was chosen a priori as the

Int J Physiother 2015; 2(2) Page | 401
threshold for statistical significance and maintained
due to the descriptive nature of the study,
RESULTS
A total of 53 subjects completed the e-mail survey tool, for a total response rate of 29%. Therapist
demographics are contained in Table 1.
Table - 1: Demographics and Training Characteristics of Physical Therapists (N=53)
Age
Frequency
Percentage
21-30
21
39.6
31-40
19
35.8
41-50
8
15.1
51-60
5
9.4
Years in practice
0-5 years
18
34.0
6-10 years
12
22.6
11-15 years
6
11.3
16-20 years
7
13.2
20-25 years
6
11.3
25+ years
4
7.5
Practice setting
academic institution
3
5.7
private practice
33
62.3
multispecialty group
5
9.4
HMO
2
3.8
Other
10
18.9
Board Certified Clinical
Specialist (OCS,SCS)
Yes
9
17.0
No
44
83.0
Fellowship/Residency
Training
Fellowship/residency
7
13.2
No fellowship/residency
46
86.8
Across all groups, the majority of therapists (58.5%)
started therapy in the 4-6 week range, and typically
treat patients following ACDF two sessions per
week(66.0%). There were no statistically significant
differences comparing treatment frequency or start
time for practice setting, years of practice, age
group, fellowship/ residency training or clinical
specialization. (Table 2)
Table – 2: Initiation and Frequency of Therapy (N = 53)
Sessions per week
Frequency
Percentage
2
35
66.0
3
15
28.3
4
1
1.9
5
1
1.9
missing data
1
1.9
Start Time
first week
1
1.9
2-3 weeks
14
26.4
4-6 weeks
31
58.5
pain controlled
1
1.9
radiographic healing
4
7.5
Missing
2
3.8

Int J Physiother 2015; 2(2) Page | 402
The majority of therapists (52.8%) across all groups
continue therapy for 4-6 weeks, with 6-8 weeks also
occurring frequently (30.2%). There was a
statistically significant difference for fellowship/
residency trained therapists tending to continue
therapy longer than non-fellowship/residency
trained therapists (χ²=9.92, p=.019, +LR 8.70).
There was no statistically significant difference in
start timing or sessions per week between
fellowship/residency trained therapists and non-
fellowship/residency trained therapists. There was
an association for specialists to see patients fewer
times per week (χ²=10.74, p=.013, +LR= 8.50),
and for therapists with more than 25 years of
experience to see patients more frequently (χ²=
28.01, p=.022, +LR = 19.99). Additionally, there
was an association between seeing a higher volume
of post operative cases and more sessions per week
(χ²= 23.44, p=.024, +LR= 14.01). There were no
statistically significant associations between
practice setting or age and the start of therapy, visits
per week, or length of continuation of therapy.
Appropriate treatment options
Physical therapists who participated were
presented with a list of 11 common treatment
modalities, and asked to select from this list the
treatments that they deemed to be appropriate for
patients following ACDF, and then a duplicate list
asking them to select those that they deemed
inappropriate for patients following ACDF. The
selected treatments are presented in Table 3.
Table – 3: Appropriateness of therapeutic modalities
Deemed appropriate
Deemed inappropriate
Response
Percent
Response
Count
Response
Percent
Response
Count
Moist Heat
86.5%
45
5.8%
3
Isometric
Strengthening
86.5%
45
9.6%
5
Endurance
exercises
73.1%
38
7.7%
4
Stretching
exercises
71.2%
37
7.7%
4
Aerobic exercise
63.5%
33
5.8%
3
Massage
61.5%
32
11.5%
6
Electrical
stimulation
59.6%
31
21.2%
11
Joint
mobilization
40.4%
21
40.4%
21
Ultrasound
26.9%
14
51.9%
27
Aquatic therapy
21.2%
11
7.7%
4
Traction
5.8%
3
90.4%
47
Treatment prioritization
The therapists were given a list of 11 common
treatments utilized in the treatment of patients in
the outpatient setting. They were instructed to rate
the interventions on a scale of 1-4, with 1 being not
at all important and 4 being very important. The
majority of therapists from the total sample
identified several treatments as being very
important in the care of patients following ACDF.
The primary treatments included endurance
exercise (60.4%), isometric strengthening (56.6%),
and stretching (45.3%). Secondary treatments,
defined as somewhat important, included aerobic
activity (somewhat 45.3%, very 35.8%, cumulative
81.1%), massage (somewhat 58.5%, very 18.9%,
cumulative 77.4%), and moist heat (somewhat
45.3%, very 17%, cumulative 62.3%). Those rated
primarily as “not at all important” were traction
(77.4%) and ultrasound (60.4%). Mobilization,
aquatic therapy and electrical stimulation were
considered neutral recommendations, with greater
than 50% of respondents rating these interventions
as slightly or somewhat important. (Table 4)
Table – 4: Therapist rankings of interventions

Int J Physiother 2015; 2(2) Page | 403
Very
important
Somewhat
Important
Slightly
Important
Not at all
Important
N
%
n
%
N
%
N
%
Endurance
32
60.4
13
24.5
7
13.2
0
0
Isometric
Strength
30
56.6
16
30.2
4
7.5
3
5.7
Stretching
24
45.3
16
30.2
10
18.9
2
3.8
Aerobic
Activity
19
35.8
24
45.3
10
18.9
Joint
Mobilization
10
18.9
13
21.5
12
22.6
15
28.3
Massage
10
18.9
31
58.5
7
13.2
4
7.5
Moist Heat
9
17.0
24
45.3
13
21.5
7
13.2
Electrical
Stimulation
6
11.3
18
34.0
13
21.5
11
20.8
Aquatic
2
3.8
12
22.6
22
41.5
13
21.5
Traction
2
3.8
3
5.7
2
3.8
41
77.4
Ultrasound
1
1.9
9
17.0
9
17.0
32
60.4
There was a significant association between
fellowship or residency training and the
prioritization of joint mobilizations (χ²= 8.40, p=.
038, +LR= 8.99). Specialists considered stretching
to be a lower priority intervention compared to non-
specialists (χ²=12.11, p=.007, +LR =10.91). There
was a strong association for those identifying as
working in private practice, academic settings and
“other” as considering isometric strengthening
important compared to those identifying as working
for an HMO (χ²= 30.26, p=.003, -LR=18.06).There
were no other statistically significant associations
between groups and specific interventions.
There were several significant correlations between
demographic variables and treatment prioritization.
Amongst the demographic variables, years of
practice was negatively correlated to specialist
status, (r=-.374, p=.006), however there were no
other statistically significant relationships between
years of practice, specialist certification, and
fellowship status. Therapists who prioritized
endurance activity also selected aerobic exercise as
an important treatment aspect, (r=.557, p<.001).
This finding was not significantly related to
specialist status, years in practice, or fellowship
status. Despite the general response regarding
modalities being appropriate but of lower priority,
there was a strong relationship for therapists who
indicated that ultrasound was important also
indicating that electrical stimulation (r=.450,
p=.001) and moist heat (r=.397, p=.004) were also
important. However, there was a moderate to
strong relationship between prioritizing
mobilizations and avoiding moist heat (r=-.349,
p=.013). These findings did not correlate to years
of practice, or specialist certification, but modality
use was correlated to a lack of fellowship training
(ES r=.350, p=.015, US r=.278, p=.048, MH
r=.344, p=.012). Inclusion of isometric exercises
was negatively correlated to the length of
continuation of therapy, (r=-.303, p=.029) without
relationship to demographic factors. However,
fellowship training also had a moderate negative
correlation to length of continuation of therapy (r=
-.395, p=.004).
Therapist Beliefs Regarding Rehabilitation
Following ACDF
The therapists were asked to rate their beliefs on a
scale of 1-5, with 1 indicating strongly disagree and
5 indicating strongly agree with a series of
statements.
In response to the statement “I believe that physical
therapy is beneficial to the patient following
cervical fusion surgery”, 57.7% (n=30) indicated
strongly agree, 36.5% (n=19) indicated agree, 3.8%
(n=2) indicated neutral, and 1.9% (n=1) strongly
disagreed.
In response to the statement “I believe that physical
therapy may be harmful to the healing of the
fusion”, no participants responded strongly agree,
5.9% (n=3) indicated agree, 7.8% (n=4) indicated
neutral, 64.7% (n=33) indicated disagree, and
21.6% (n=11) indicated strongly disagree.
In response to the statement “I believe that the
patient is able to recover full function without post
operative intervention”, no participant responded
strongly agree, 9.6% (n=5) agreed, 34.6% (n=18)
indicated neutral, 42.3% (n=22) indicated disagree,
and 13.5% (n=7) indicated strongly disagree.
In response to the statement “My patients have had
negative experiences with post-operative physical
therapy”, no participant responded strongly agree,

Int J Physiother 2015; 2(2) Page | 404
3.8% (n=2) indicated agree, 7.7% (n=4) indicated
neutral, 53.8% (n=28) indicated disagree, and
34.6% (n=18) indicated strongly disagree.
In response to the statement, “Patients have better
outcomes with the inclusion of post-operative
physical therapy”, 44.2% (n=23) indicated strongly
agree, 46.2% (n=24) indicated agree, 7.7% (n=4)
indicated neutral, and 1.9% (n=1) indicated s
trongly disagree. There were no statistically
significant associations between response and any
grouping for age, fellowship/residency training,
practice setting, clinical specialist status, or years of
practice across all measures for therapist belief.
Correlations of beliefs
Therapist response that therapy is beneficial to the
patient was strongly correlated to patients having
improved outcomes with post operative therapy,
r=.591, p<.001. This response was negatively
correlated to believing that patients could achieve
full function without post operative care (r=-.412,
p-.002), as well as reporting that patients have had
negative experiences with therapy (r=-.527,
p<.001). Responses indicating that patients achieve
superior outcomes with therapy also demonstrated
a negative correlation to believing that patients
could achieve full function without post operative
care (r=-.500, p<.001), as well as reporting that
patients have had negative experiences with
therapy (r=-.416, p=.002). However, for therapists
reporting that they felt therapy may be harmful to
the fusion, there was a statistically significant
correlation to reporting that their patients have had
negative outcomes as a result of therapy (r=.284,
p=.041).
DISCUSSION
The purpose of this study was to establish physical
therapists current practice patterns and beliefs
regarding rehabilitation following ACDF,
establishing data regarding usual physical therapy
care during the post-operative period. To our
knowledge, there has not been specific research
performed to determine either the role of physical
therapy following ACDF surgery or the types of
therapy performed. Therefore, establishment of
baseline data is required to develop appropriate
protocols for comparison of various modes of care
for use in post-operative rehabilitation studies.
The results of this study revealed several trends in
clinical care following ACDF. Therapists strongly
believed that post-operative rehabilitation results in
improved functional outcomes that would not have
been attained by the patient on their own. This is
in line with the current evidence suggesting that
while pain is resolved following ACDF, other
deficits remain.1,6,8 Therapists emphasized the use
of active rehabilitation featuring endurance
exercises, isometric strengthening, stretching, and
aerobic activity, while placing a lower emphasis on
passive modalities. The majority of respondents
reported initiation of therapy between 4-6 weeks. As
most patients would then be beyond the acute stage
of healing, pain management may be a lower
priority, and passive modalities may be under-
represented as a result. Interestingly, while the
majority of therapists deemed modalities to be
appropriate, very few placed a high priority on their
usage in this population. Those therapists
indicating a higher priority of ultrasound, however,
were also likely to place a high priority on moist
heat and electrical stimulation. This may represent
an alternative practice pattern for this post
operative population.
We were unable to identify any randomized trials
evaluating the effects of physical therapy during the
post-operative period following cervical spine
surgery. Findings from observational studies have
elucidated various factors related to disability
following ACDF. Previous research9 found an
association between decreased neck muscle
endurance and continued pain and disability
following ACDF. Neck muscle endurance (NME)
deficits were directly correlated to higher levels of
disability suggesting that specific training for NME
should be incorporated into the rehabilitation
program. Additional studies3examined short term
results following ACDF (6 months) to see if long
term results (3 years) could be predicted. At three
years after ACDF, approximately two-thirds of the
patients had deficits related to pain intensity and
function. These findings led to the conclusion that
while these problems are multi-factorial, the
inclusion of strength and endurance activities may
improve long-term outcome.
Based on the consensus of respondents, there is a
strong feeling that patients benefit from the
inclusion of post-operative rehabilitation. The
specific recommendations included endurance
exercises, isometric strengthening, stretching,
aerobic activity, and to a lesser extent massage and
moist heat. These active treatment interventions
appear to be specifically targeted at restoring
function rather than provide symptomatic relief.
This also coincided with a strong recommendation
away from passive modalities such as ultrasound
and traction in the post-operative period.
Incorporating appropriate active rehabilitation
following fusion may lead to better results and
decreased overall expenditures. As such, our
findings are in agreement with the suggestions of
previous authors.

Int J Physiother 2015; 2(2) Page | 405
Manual therapy has been supported by the best
available evidence for the treatment of cervical
radiculopathy,10,11 however there seems to be a
general lack of consensus regarding the use of joint
mobilizations following ACDF. In fact, our sample
presented with a near equal distribution of answers
regarding the prioritization of its use. While
certainly contraindicated at the level of fusion,
there may be a role for manual therapies directed at
the surrounding levels/tissues. Current theories,
including regional interdependence12,13, as well as
the neurophysiologic effect of manual therapies on
pain modulation14 may justify a role for such
techniques in the management of patients following
ACDF. The association of mobilization use with
fellowship-residency training may represent a
selection bias, as these individuals are more likely
to have specialized training in the use of manual
therapy techniques. This training, however, would
also qualify these individuals the experts in the use
of these techniques, and may indicate an area in
need of further study.
In our sample, there was an association for
specialists to see patients fewer times per week.
This corresponds to previous findings regarding the
care of neck pain relative to education. Magel et al15
reported that the number of sessions of care
decreased in response to specific education
regarding care of neck pain. Conversely, in the
current study, therapists indicating >25 years of
experience was strongly associated with seeing
patients more frequently. While we could find no
direct data associating experience to therapy
utilization, prior research has reported on the
association of experience to evidence based
practice. 16Their findings indicated a strong
association with younger/less experienced physical
therapists utilizing evidence and performing critical
appraisal to aide their practice, while progressive
years of experience were associated with a
decreased use of evidence. They reported that
therapists with <5yrs experience reported a 4.6x
greater use of evidence when compared to
therapists with 15yr+ years of experience.
Concurrently, therapists in the 20-29 year old range
reported that they were 22.7x more likely to have
received formal training in critical appraisal when
compared to therapists in the 50yo+ category. The
current study population demonstrated a negative
correlation between years in practice and specialist
certification. As a result, the reported high levels of
therapy utilization in the more experienced group
may be related to the reported trend towards lower
levels of evidenced based practice.
There were several limitations for this study. The
survey was only issued to a single geographic
region, and may have detected only local practice
patterns. These patterns and beliefs may not be
those of therapists in other regions. While intended
to determine current practice, our survey did not
differentiate whether treatment choice was at the
therapist’s discretion or if it was prescriptive in
nature, nor did we attempt to differentiate
treatment choice based on the immediate goals of
treatment, instead focusing on a more global view
of ACDF rehabilitation. Our sample was heavily
weighted towards therapists in a private practice
setting, and one-third of respondents were novice
practitioners with less than 5 years of experience.
It should therefore be noted that due to a limited
sample size, as well as a possible selection bias from
the sample of convenience who chose to
participate, these findings may not be applicable to
all rehabilitative settings. While the response rate
of 29% was better than generally expected for a
survey instrument, and the overall sample of 53 is
large enough to allow for some generalizations to be
made, there is also a possibility of selection bias, as
those who chose to respond may have different
practice patterns and beliefs than those who chose
not to respond. Finally, the survey instrument
utilized to perform this study has not been subjected
to statistical validation.
CONCLUSION
The results of the study indicate several
recommendations for the utilization of physical
therapy following ACDF. Over 90% of therapists
surveyed believe that therapy is beneficial for the
patient following ACDF. Therapy is utilized in
most cases twice weekly, and for 6 weeks duration.
During these sessions, the focus is on endurance
exercises, isometric strengthening, stretching,
aerobic activity, and to a lesser extent massage and
moist heat. These active treatment interventions
appear specifically targeted to regain function
rather than provide symptomatic relief. Future
research to examine the efficacy of postoperative
rehabilitation in improving clinical outcomes and
preventing disability in patients who have
undergone ACDF is needed.
Acknowledgements: The authors would like to
thank Ms. Lindsay McDermott and Mr. Mark
Gombotz of Select Medical Corp. and Mr. Michael
Gans of Physical Therapy and Sports Medicine
Centers/Connecticut Physical Therapy Association
OMT SIG for their assistance in the recruitment of
participants for this study, and Dr. Mark Cote for his
assistance in editing this paper. The authors also
thank R. Alexander Mohr, MD and Sean P. Riley PT,
ScD, OCS for their assistance in the content
validation for this survey.

Int J Physiother 2015; 2(2) Page | 406
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
REFERENCES
1. Hessler C, Boysen K, Regelsberger J, Vettorazzi
E; Winkler D, Westphal M. Patient Satisfaction
After Anterior Cervical Discectomy and Fusion
Is Primarily Driven by Relieving Pain. Clinical
Journal of Pain. 2012;28(5):398–403.
2. Checo FJ, Swanson B, Leger R, Mohr RA.
Cervical Spine Postoperative Practice Patterns:
Variations in cervical collar, imaging and
physical therapy utilization. SpineLine. 2012:27-
30.
3. Peolsson A, Vavruch L, Oberg B. Can the results
6 months after anterior cervical decompression
and fusion identify patients who will have
remaining deficit at long-term? Disabil Rehabil.
2006;28(2):117-24.
4. Hacker RJ, Cauthen JC, Gilbert TJ, Griffith SL.
A prospective randomized multicenter clinical
evaluation of an anterior cervical fusion cage.
Spine. 2000;25(20):2646-54.
5. Casha S, Fehlings MG. Clinical and radiological
evaluation of the Codman semiconstrained load-
sharing anterior cervical plate: prospective
multicenter trial and independent blinded
evaluation of outcome. J Neurosurg. 2003;(99:
Suppl):264-70.
6. Peolsson A, Peolsson M. Predictive factors for
long-term outcome of anterior cervical
decompression and fusion: a multivariate data
analysis. Eur Spine J. 2008;17(3):406-14.
7. Wang MC, Kreuter W, Wolfla CE, Maiman DJ,
Deyo RA. Trends and variations in cervical
spine surgery in the United States: Medicare
beneficiaries, 1992 to 2005. Spine. 2009;34(9):
955-61.
8. Peolsson A, Vavruch L, Öberg B. Disability after
Anterior Decompression and Fusion for
Cervical Disc Disease. Adv Physio.
2002;4(3):111-24.
9. Peolsson A., Kjellman G. Neck muscle
endurance in nonspecific patients with neck
pain and in patients after anterior cervical
decompression and fusion. J Manipulative
Physiol Ther. 2007 Jun;30(5):343-50.
10. Salt E, Wright C, Kelly S, Dean A. A systematic
literature review on the effectiveness of non-
invasive therapy for cervicobrachial pain. Man
Ther. 2011;16(1):63-5.
11. Hurwitz E, Carragee E, van der Velde G, Carroll
L, Nodin M, Guzman J,et al. Treatment of Neck
Pain: Noninvasive Interventions Results of the
Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders. Eur
Spine J. 2008;17(suppl 1):123-52.
12. Wainner R, Whitman J, Cleland J, Flynn T.
Regional Interdependence: A Musculoskeletal
Examination Model Whose Time Has Come. J
Orthop Sports Phys Ther. 2007;37(11):658-60.
13. Cleland JA, Childs JD, McRae M, Palmer JA,
Stowell T. Immediate effects of thoracic
manipulation in patients with neck pain: a
randomized clinical trial. Man Ther.
2005;10(2):127-35.
14. Sterling M, Jull G, Wright A. Cervical
mobilisation: concurrent effects on pain,
sympathetic nervous system activity and motor
activity. Man Ther. 2001;6(2):72-81.
15. Magel J, Cleland JA, Fritz JM, Brennan G. Does
Continuing Education Improve Physical
Therapists' Effectiveness in Treating Neck Pain?
A Randomized Clinical Trial. Phys Ther.
2008;89(1):38-47.
16. Jette DU, Bacon K, Batty C, Carlson M, Ferland
A, Hemmingway RD, et al. Evidence-Based
Practice: Beliefs, Attitudes, Knowledge, and
Behaviors of Physical Therapists. Phys Ther.
2003;83(9):786-805.
Citation
Brian T. Swanson, Robin R. Leger. (2015). PHYSICAL THERAPY FOLLOWING ANTERIOR CERVICAL
DISCECTOMY AND FUSION: A STUDY OF CURRENT CLINICAL PRACTICE AND THERAPIST
BELIEFS. International Journal of Physiotherapy, 2(2), 399-406.