Interventions

All patients were permitted to sit upright and walk starting the day after surgery. The epidural drain was removed 2 days postsurgery, followed by the initiation of the interventions. Patients were hospitalized at the author's institution for 2 weeks postsurgery. They were provided with a booklet describing the voluntary training method for each intervention at the time of discharge and encouraged to implement voluntary training and record its status daily. Patients who had implemented voluntary training were subsequently transferred to a recovery-phase rehabilitation hospital for approximately 2-3 weeks. Similar interventions were continued at the recovery-phase rehabilitation hospital. All patients were discharged home approximately 1 month postsurgery.

Cervical extensor isometric muscle strengthening and cervical range of motion exercise.

a, b; Cervical extensor isometric muscle strengthening. c; Active assistive range of motion exercises (cervical rotation). d; Active range of motion exercises (cervical extension). e, f, g; Manual stretching (sternomastoid muscle, scalene muscle, trapezius (upper), rhomboids, and levator scapula). h; Scapula exercises. i; Correction of the forward head posture. Written consent has been obtained for this figure.

Starting on postoperative day 2, while lying in the supine position, patients performed the exercise of pushing and holding a pillow in the direction of neck extension for 5 s 10 times (3 sets).

The cervical ROM exercise was an active assisted exercise, in which patients performed active exercise in the supine position in the left-right rotation direction, assisted by a therapist in the same direction within manageable pain.

Patients capable of self-exercise were also instructed to perform an exercise for isometric muscle strengthening in the direction of neck extension while seated and cervical extension ROM exercise to standing.

The cervical paraspinal, neck flexion, and trapezius muscles were manually stretched in the supine position. Patients were instructed to frequently move the scapula in each direction daily.

No exercise was performed on the neck after postoperative day 2, and cervical movement was recommended as long as the pain did not increase. Instructions on stretching around the neck, shoulder girdle, and cervical posture were provided by a therapist.

For patients with a forward head posture (FHP) in the sitting and standing postures, the FHP was corrected by visual feedback using a mirror in both groups E and C.

As a precaution in daily life, they were instructed not to keep their gaze downward.

When discharged from the first author's institution, patients in group E were provided with a booklet describing the methods of neck extension isometric muscle strengthening and cervical ROM exercises similar to those performed at the institution, and instructions on proper sitting posture and precautions in daily life.

Patients who performed self-exercise at least once daily after discharge were required to record it on a calendar and report at 3 months postsurgery.

At the time of final evaluation, the implementation rate of self-exercise (number of days performed/number of days from discharge to final evaluation date×100) was calculated for group E.

Patients in group C were provided with a booklet describing proper sitting posture and precautions in daily life. In addition, the patients were advised to lead a normal life and not perform any voluntary neck strengthening or ROM exercises.