Application effect of diversified health-promoting models on rehabilitation exercises for cervical spondylotic myelopathy

Abstract

BACKGROUND:

With improving living standards, the incidence of cervical spondylotic myelopathy (CSM) has become increasingly high.

OBJECTIVE:

The study aims to explore the effect of diversified health-promoting models on rehabilitation exercises in patients with CSM after an operation.

METHOD:

This was a randomized controlled trial, wherein 107 patients with CSM treated by neurosurgery were selected as the subjects. Of those, 52 patients in the control group adopted the conventional health-promoting model, while the remaining 55 patients in the intervention group adopted diversified health-promoting models. The effect of rehabilitation exercises in the two groups was evaluated according to the self-efficacy rehabilitation outcome scale, grip strength measurement of the affected limb, and Barthel index.

RESULTS:

At Day 3 post-operation and before discharge, the self-efficacy management of rehabilitation exercises in the intervention group was better than that of the control group ( $P<$ 0.05). The grip strength measurement of the affected limb, Japanese Orthopedic Association score of the cervical vertebra, and Barthel index of the two groups at Day 3 post-operation were lower than before the intervention and were not statistically significant ( $P>$ 0.05). However, these three items before discharge were improved when compared with those of before intervention and were statistically significant ( $P<$ 0.05).

CONCLUSION:

Postoperative rehabilitation exercises guided by the diversified health-promoting models for patients with CSM can improve the patients’ self-efficacy management ability in rehabilitation exercises, help improve grip strength, and promote the recovery of cervical vertebra function, thereby improving the patients’ quality of life.

Keywords

Diversified health-promoting publicity and education cervical spondylotic myelopathy rehabilitation exercise

1. Introduction

With improving living standards, the incidence of cervical spondylotic myelopathy (CSM) has become increasingly high, which takes a toll on people’s health and quality of life [1]. It is generally believed that once CSM is diagnosed, surgery should be performed as soon as possible to prevent disease progression, preserve neurological function, and maximize the patients’ recovery chances [2]. Anterior cervical discectomy fusion (ACDF) is an effective method for the treatment of CSM and is characterized by a small incision, less bleeding, and good postoperative recovery [3, 4]. Studies have confirmed [5] that effective guidance on functional exercises for CSM patients who have undergone surgery can help improve postoperative rehabilitation and promote the effective recovery of spinal cord functions. Health promotion [6] is usually defined as “the process of enabling people to increase control over and improve their health”, which has been applied to chronic diseases [7, 8], mental health [9, 10], children treatment [11] and so on, and achieved good results. Diversified health-promoting models mainly refer to the process where medical staff implement systematic and personalized health education for patients using various forms of publicity and education and following standardized health publicity and education principles to promote patient health [12]. This not only helps patients to better understand the disease but also relieves them of negative emotions and promotes their compliance with medical advice. On the other hand, the strategy of health education is an important means of nursing [13]. The application of different educational methods can effectively promote the progress of skills [14]. However, conventional health education methods are limited, which stay in oral education, dialogue health education, and provide guidance only when problems occur [15, 16, 17, 18]. Patients and their families cannot effectively receive and implement rehabilitation exercise, resulting in uneven quality of postoperative rehabilitation exercise. Therefore, the use of health-promoting methods to improve the effectiveness of and compliance with rehabilitation exercises in patients who have received ACDF is of great significance for improving their rehabilitation and speeding up recovery. This study introduced the concept of accelerated rehabilitation surgery which is the source of our model framework and adopted diversified health-promoting models to carry out rehabilitation exercise for patients who have undergone CSM surgery, the purpose of which is to improve patients’ self-management ability of rehabilitation exercise and promote the recovery of cervical spine function, so as to improve the quality of life. The findings are reported as follows.

2. Subjects and methods

2.1 Subjects

This randomized controlled trial was approved by the Ethics Committee of Fujian Medical University Union Hospital (Ethics No.: 2020YF34-01). It is one of the core contents of a multicenter, randomized controlled study on the evaluation of the efficacy of accelerated, enhanced recovery during the perioperative period of CSM (Registration No.: ChiCTR2000040508). Using the random number method with a computer, CSM patients who underwent surgical treatment in the neurosurgery department between November 2020 and June 2022 were selected as the subjects and divided into the control group and intervention group. The inclusion criteria were as follows: (1) met the diagnostic criteria for CSM [19]; (2) aged 18 years old and above; (3) good language expression and comprehension ability; and (4) no other cervical vertebral complications. The exclusion criteria were as follows: (1) history of cervical spine surgery; (2) combined with other severe organic diseases that cause pathological changes in an organ or a tissue system, resulting in functional decline or loss irreversibly, and even unstable vital signs, (such as serious heart disease, active malignancies, acute infectious diseases, liver and kidney function impairment, etc.) which may affect the patient’s recovery; (3) patients with limited mobility due to severe postoperative complications which may affect recovery from surgery, aggravate the condition, or even lead to life-threatening conditions (such as infection, internal bleeding, pulmonary embolism, myocardial infarction, pneumonia, stroke, etc.); (4) preoperative limb dysfunction not caused by cervical spondylosis. All patients were provided with and signed the informed consent.

Figure 1.

Neck hyperextension exercise.

2.2 Study methods

•
The control group adopted the conventional health-promoting model [20, 21, 22, 23], with the following specific contents: (1) On admission, patients and their families were introduced to the relevant knowledge of the disease, including environmental facilities and safety introduction, basic knowledge of the disease, medical staff in charge, etc., especially to inform the adverse lifestyle causing cervical spondylosis; (2) the day before the operation, the preoperative precautions were explained to them: neck support wearing, deep breathing training, neck hyperextension exercise (Fig. 1), tracheal push-pull exercises (Fig. 2), bed urination training, fasting and water deprivation, etc.; (3) postoperative guidance on matters need to attention. For example, A. Disease observation: the vital signs, blood and fluid infiltration of the operative wound, muscle strength and muscle tension of the limbs were observed; B. Body position: use a sandbag to immobilize the patient’s neck and restrict one’s movement; C. Diet: fasting for 6 hours on the day of surgery was followed by a gradual transition from a liquid diet to a regular diet; D. Activities: guide ankle pump exercise in bed to prevent deep vein thrombosis, clench exercises for muscle strength and tone recovery, along with stand and walk with caregivers when out of bed activities; E. Psychology: at the end of shift every morning, assess and ask patients about their recovery progress, encourage and praise them more, and improve their confidence in recovery; (4) rehabilitation exercise guidance was provided in the forms of oral publicity, education, and demonstration after the patient’s condition was stable; (5) for patients with poor compliance, special notes were handed over to the next shift, and enhanced guidance was given during ward rounds or bedside shifts; and (6) other issues raised by patients and their families were solved proactively.

Figure 2.
Tracheal push-pull exercises.

•
Based on the conventional publicity and education model, the intervention group adopted diversified health-promoting models by integrating the concept of enhanced recovery surgery [24] and aligning theory with practices to provide patients with guidance on individualized rehabilitation. The content was as follows:

(1)
Development of a perioperative rehabilitation exercise plan for patients receiving ACDF, which was guided and implemented daily by the responsible nurse. The plan focused on moving forward with rehabilitation and implementing pre-rehabilitation, which means that the guidance on the rehabilitation exercises that was supposed to be given after the operation was provided for patients before the surgery. This enabled the patients to master the postoperative rehabilitation exercises in advance, with a view to preventing them from failing to coordinate or master the exercises due to body position, weakness, or declined somatic function after the operation. The pre-rehabilitation included wearing collar support, training the pelvic floor muscle, venous thromboembolism prevention measures, breathing exercises, and position adaptive training. Postoperative rehabilitation exercises were implemented in stages. For on-bed activities at Day 1 after surgery, the patients were provided with guidance on turning over around the axis, correct position switching from lying to sitting, and bedside sitting balance training, with the goal of maintaining sitting balance for 10 minutes. Additionally, the patients were encouraged to finish eating and washing in bed to make them less dependent on family companionship and improve their self-care ability. At Day 2 after surgery: the patients were instructed to complete position switching from sitting to standing and were given standing balance training to improve their transfer and mobility ability in preparation for walking training. At Day 3 after surgery, the patients were provided with training on indoor walking, twice a day at 20 minutes per time, and encouraged to perform daily activities, such as grooming, bathing, and toileting. From Day 4 after surgery to before discharge, the patients went over the contents of the first 3 days and adopted these as regular, normalized rehabilitation exercises.
(2)
Patients receiving ACDF were provided with publicity and education on rehabilitation exercises according to concise schematic diagrams of, for example, neck hyperextension, pelvic floor muscle exercises, pushing and pulling exercises, and turning over around the axis, wherein the key points and details were presented by combining images and texts in a dynamic, unambiguous way, with a view to enabling both patients and their families to master the rehabilitation exercises as quickly as possible.

Figure 3.
Mini upper-limb training machine.

Figure 4.
An adjustable restraint device for neck rehabilitation – the neck immobilizer.

(3)
The patients were shown neck and shoulder muscle relaxation exercises to relieve tension and shoulder and neck pain after the operation. The postoperative recovery was accelerated, and the problems arising from postoperative neck fixation, such as the decrease in the range of motion and strength of adjacent shoulder and back, were reduced. Our team designed a set of postoperative neck and shoulder relaxation exercises, including the following actions: 1) shoulder surrounding; 2) standing breaststroke; 3) chest expansion; 4) straight arm circling; 5) exercise against the wall; and 6) self-massage the superior trapezius bundle (starting from the external occipital protuberance, superior nuchal line, ligamentum nuchae, the seventh cervical vertebra, and ending with the lateral 1/3 of the clavicle, spine of scapula, and acromion). It was recommended that each exercise was performed 10–15 times, and the full set of exercises was performed 3–5 times, 2–3 times a day, and this was carried out gradually according to the patients’ conditions.
(4)
Instruction of an upper-limb muscle strength exercise was provided, where the patient held one side of the rotating shaft of a mini upper-limb training machine with their hand on the affected side and shook the training machine to make it rotate using their own strength (Fig. 3). This could be done from the first day after the operation, twice a day for 30 minutes each time. For patients with low muscle strength on the affected side, the upper-limb muscle strength exercise was driven by the unaffected side.
(5)
Video rehabilitation guidance was provided, and relevant education regarding rehabilitation exercises was played on the television in the ward twice a day, including information on the correct wearing of collar support, getting in and out of the bed correctly, prevention of constipation, and knowledge of cervical spine prevention and treatment. The responsible nurse guided and supervised the correctness of the patients’ rehabilitation exercise. And adjustments were made in a timely manner.
(6)
Regarding the design and application of the neck immobilizer, the team independently designed a device that can stabilize and immobilize the neck – the neck immobilizer (Fig. 4). Compared with sandbags, this device can more effectively immobilize the head to limit the motion of the neck. Moreover, it can also adjust the width of the occipital personalized, which means the device can be applied to different postures, and suitable for matching different head circumference of patients who may feel comfortable and conducive to neck rehabilitation (Figs 5 and 6).

Figure 5.
The use of the neck immobilizer in the patient’s lateral decubitus position.

Figure 6.
The principle of the neck immobilizer adjusts the position.

2.3 Evaluation index

2.3.1 Self-efficacy rehabilitation outcome (SER) scale

The scale includes two dimensions and a total of 12 items, namely coping self-efficacy (7 items) and physical exercise self-efficacy (5 items). It was developed by Waldrop et al. [25] and has a high level of reliability and validity [26]. (Cronbach’s $\alpha$ was 0.954, and the validity index was 0.95). Each item was scored from 0 to 10 points, ranging from “completely unconfident” to “completely confident”, with a total of 0 to 120 points. The higher the score, the higher the self-efficacy of the rehabilitation exercise, and the higher the compliance with rehabilitation exercise.

2.3.2 Measurement of grip strength

Grip strength mainly tests the development degree of the upper-limb muscle groups as an index that reflects the development level of human upper-limb strength. The electronic hand dynamometer manufactured by Guangdong Senssun Weighing Apparatus Group Ltd. (model: CAMPY EH101) was used. The measurement method was as follows: The patient, standing erect with feet shoulder-width apart, gripped the dynamometer in the upper limb on the affected side and placed it on the side of the body naturally. After that, the data was read for 3 seconds continuously, and then a remeasurement was performed at an interval of 1 minute. The average value of three consecutive measurements was taken as the result.

2.3.3 Japanese Orthopaedic Association (JOA) cervical vertebra scale [27]

This scale comprehensively evaluates four aspects that are commonly affected in CSM patients, namely upper-limb movement (including flexibility), lower-limb movement (including transition state), sensation, and bladder function, with a total score of 17 points. CSM can be divided according to the following degrees of severity: mild: $\geqslant$ 15 points; moderate: 12–14 points; and severe: $<$ 12 points.

2.3.4 Evaluation of activities in daily life

The Barthel index [28] was used to evaluate the patients’ self-care ability in daily life, including eating, bathing, grooming (including washing face, brushing teeth, shaving, and brushing hair), dressing (such as tying shoelaces), defecation control, urination control, toileting (including cleaning and arranging clothes after defecation), transfer between bed and wheelchair, walking on level ground, and walking up and down stairs. A total of 10 items needed to be scored to evaluate the functional status and predict the prognosis of patients before and after treatment. According to the extent of the patients’ need for help, the scale was divided into the following four grades: 15 points, 10 points, 5 points and 0 points. The maximum score was 100, and the minimum was 0. The higher the score, the stronger the independence of the patient, and the better the recovery of the patient. The scale is currently the most common evaluation method for activities in daily life in clinical practice [29], with good reliability, validity, and sensitivity.

2.4 Evaluation timing

The above indexes were evaluated before the intervention, at Day 3 after the operation, and before discharge in the two groups.

2.5 Quality control

By combining the online inquiry with offline completion, the investigators explained to the patients, using standardized instructions, how to fill in the questionnaire, so as to ensure that the patients completed the questionnaire according to their true willingness. Patients were required to complete the questionnaire independently in a quiet environment, free from interference from families or other external distractions. Any question that was raised by the patients was explained by the investigators without interfering with the patients’ judgment. General practice nurses were trained on the measurement of grip strength by the investigators. All data were checked by investigators for completeness and authenticity.

2.6 Data processing

The statistical data were analyzed with using SPSS 23.0 software. The measurement data were described by the mean and standard deviation, and the comparison between the two groups was performed by an independent sample $t$ -test. Enumeration data used the frequency and composition ratio to describe the demographics of the patients, and the comparison between the two groups was carried out using an $\chi^{2}$ test or rank sum test. $P<$ 0.05 was considered statistically significant.

3. Results

3.1 Analysis and comparison of the demographics between the two groups

A total of 107 cases were enrolled in this study, including 52 cases in the control group and 55 in the intervention group. There was no statistically significant difference between the two groups in terms of the gender, age, education level, surgical method, postoperative complications, length of stay, and other demographics ( $P>$ 0.05). The result is comparable and shown in Table 1 in detail.

Table 1
Comparison of demographics between two groups ( $n$ , %, x $\pm$ s)

Item/group		Intervention group ( $n=$ 55)		Control group ( $n=$ 52)		$\chi^{2}/t$	$P$
		Number of cases	%	Number of cases	%
Gender	Male	36	65.5	36	69.2	0.677	0.173
	Female	19	34.5	16	30.8
Education	Junior high school degree and below	37	67.3	35	67.3	0.960	0.083
	High school, technical secondary school	13	23.6	13	25
	or junior college degree
	University diploma or above	5	9.1	4	7.7
Operation mode	Anterior	47	85.5	40	76.9	1.280	0.258
	Posterior	8	14.5	12	23.1
Complications	No	49	89.1	45	86.5	0.163	0.686
	Yes	6	10.9	7	13.5
Age (years)		58.87 $\pm$ 9.41		58.25 $\pm$ 8.60		0.357	0.722
Length of stay (day)		8.27 $\pm$ 1.56		8.48 $\pm$ 1.46		$-$ 0.712	0.478

3.2 Comparison between the two groups in terms of the SER scores, grip strength of the affected limb, and JOA cervical vertebra function score before and after intervention

There was no statistically significant difference in the SER scores between the two groups before intervention ( $P>$ 0.05), but there were statistically significant differences in the scores between the two groups at Day 3 after the operation and before discharge ( $P<$ 0.05). There was no significant difference in the grip strength of the affected limb, JOA cervical spine function score, or Barthel index between the two groups before the intervention and at Day 3 post operation ( $P>$ 0.05), but there were statistically significant differences in the values before discharge ( $P<$ 0.05). The specific results are shown in Tables 2–5.

Table 2
Comparison of self-efficacy assessment for rehabilitation outcome between two groups (X $\pm$ S, score)

Group	Number of cases	Pre-intervention	Day 3 post operation	Prior to discharge
Intervention group	55	65.40 $\pm$ 10.15	73.58 $\pm$ 8.87	81.82 $\pm$ 6.95
Control group	52	65.44 $\pm$ 6.64	70.25 $\pm$ 7.62	75.33 $\pm$ 7.66
$t$		$-$ 0.025	2.080	4.596
$P$		0.980	0.040	$<$ 0.001

Table 3

Comparison of grip strength of affected limb between two groups (X $\pm$ S, score)

Group	Number of cases	Pre-intervention	Day 3 post operation	Prior to discharge
Intervention group	55	17.97 $\pm$ 6.84	16.89 $\pm$ 6.31	21.05 $\pm$ 6.79
Control group	52	17.61 $\pm$ 7.04	16.89 $\pm$ 6.56	18.38 $\pm$ 6.49
$t$		0.269	$-$ 0.003	2.072
$P$		0.788	0.998	0.041

Table 4

Comparison of JOA scores between two groups (X $\pm$ S, score)

Group	Number of cases	Pre-intervention	Day 3 post operation	Prior to discharge
Intervention group	55	11.91.27 $\pm$ 1.88	11.53 $\pm$ 1.39	13.64 $\pm$ 1.22
Control group	52	11.77 $\pm$ 1.91	11.52 $\pm$ 1.24	12.83 $\pm$ 1.25
$t$		0.896	0.253	3.388
$P$		0.703	0.975	0.001

Table 5

Comparison of Barthel index between two groups (X $\pm$ S, score)

Group	Number of cases	Pre-intervention	Day 3 post operation	Prior to discharge
Intervention group	55	87.27 $\pm$ 8.54	80.82 $\pm$ 6.86	94.27 $\pm$ 4.56
Control group	52	86.54 $\pm$ 8.72	80.38 $\pm$ 7.33	91.44 $\pm$ 5.08
$t$		0.901	0.539	3.037
$P$		0.661	0.753	0.003

4. Discussion

As the main body of health educators, medical staff plays a key role in the creation, management, and monitoring of health-promoting plans [30]. However, as health educators’ levels of relevant knowledge and health education ability vary, individualized health education for patients may not be implemented properly, which directly affects the recovery of patients. The study adopted diverse health-promoting models to improve the enthusiasm of patients for postoperative rehabilitation exercises, effectively promote the rapid recovery of patients, and improve their quality of life.

4.1 Diversified health promotion models help improve patients’ self-management abilities of rehabilitation exercises

Doing more exercises is beneficial for the rehabilitation of patients with cervical spondylosis [31] and is an effective method to relieve neck pain and improve patients’ quality of life [32, 33, 34]. In this paper, patients carried out postoperative rehabilitation exercises based on the established diversified health publicity and education models. Compared with the group that adopted the conventional model, the group that adopted diversified health-promoting models recorded an ever-improving self-efficacy of rehabilitation exercises, reaching (81.82 $\pm$ 6.95) points upon discharge. This marks a significant improvement when compared with the survey carried out by Pan [23] on the self-efficacy of rehabilitation exercises in 102 patients after CSM surgery. Diversified publicity and education models, which are widely accessible and present rich contents, can galvanize patients into exercises, make them more invested in rehabilitation exercises, and improve their compliance with medical advice. Therefore, patients can better manage their rehabilitation exercises, which is of great clinical significance for the recovery of cervical vertebra [35] and can accelerate the recovery process. This is in line with the point summarized by Barbari et al. [36], that diversified education models for patients with chronic low back pain can improve postoperative compliance and spinal function.

4.2 The diversified health-promoting models help improve the patients’ grip strength and promote the functional recovery of cervical vertebra

Studies have confirmed [37] that a change in grip strength is an objective indicator of the change of hand muscle strength in patients with CSM after surgery, which reflects the recovery of the cervical spine function. Early postoperative hand function rehabilitation exercises can help promote the recovery of the cervical spine function [38]. According to Tables 3 and 4, the measurement of grip strength and JOA score of the affected limb after operation in the two groups of CSM patients, who adopted different publicity and education models, decreased slightly at Day 3 after the operation and then improved again before discharge. This indicates that both groups of rehabilitation publicity and education models were effective, but the patients receiving diversified education models recorded significantly higher grip strength and JOA scores than those of the control group ( $P<$ 0.05). The decrease in both grip strength and JOA scores at Day 3 after the operation may be related to the operation. The traction in the operation and implantation of the artificial cone may result in traumatic reactions at the surgical site and adjacent tissues, and this needs time to recover. In addition, the fixation of collar support, body position, wound pain, and pipeline can affect the patient’s activities and measurements. At this time, the body function is still in a state of gradual recovery. With the intervention of the diversified publicity and education models and based on the consensus achieved by nurses and patients on enhanced recovery, the patients continue to advance through the staged rehabilitation exercises, and the rehabilitation exercises gradually become normalized. Therefore, before discharge (average 8 days after surgery), the JOA score of patients in the intervention group was higher than that of the control group. The reason for this result was not only the gradual recovery of surgical trauma, but also the gradual promotion of rehabilitation exercise. The upper-limb mini-functional exercise instrument can improve the patients’ compliance with training, make the exercise more interesting, and encourage the patients to be more invested in the functional exercise. Additionally, the neck and shoulder muscle relaxation exercises can promote the adjustment of local blood circulation and effectively relieve the pain of the patients by massaging and stimulating the neck and shoulder muscles, such as the trapezius muscle, and is conducive to the effective recovery of the cervical spine function. Therefore, a much better intervention effect can be achieved. This is consistent with the finding by Park et al. [39] that strengthening the trapezius can promote cervical spine rehabilitation. In addition, the neck immobilizer can effectively improve the comfort of the patient during braking and maintain the physiological curvature of the neck, which is beneficial to postoperative rehabilitation.

4.3 Diversified health-promoting models can improve patients’ activities in daily life and their quality of life

Studies have shown [40, 41, 42, 43] that a sound publicity and education model is conducive to improving patients’ activities in daily life and their quality of life. The present study also revealed that based on the diversified health-promoting models, the Barthel index of the patients before discharge was significantly improved compared with that of the control group ( $P<$ 0.05), suggesting that the effect of the intervention group improved both the patients’ activities in daily life and their quality of life. Compared with the traditional education model, diversified health-promoting publicity and education are characterized by diversified forms and rich contents, which is conducive to improving the learning enthusiasm of patients and can meet the varied demands of patients with different individual characteristics for health education, with a view to maximizing the effect of that education [19]. In this way, knowledge and rehabilitation concepts can be translated into healthy behaviors. By diversifying health-promoting methods, it is possible to improve the compliance of patients and enable them to actively participate in their own daily nursing, thereby achieving the rapid transition from alternative nursing to self-care. In this way, both the self-care ability of patients in daily life and their quality of life can be improved.

4.4 Limitations

Due to the small sample size, this study failed to make a stratified analysis of the confounding factors that may affect patients’ rehabilitation exercises, such as the patients’ mental status, nutritional status, and family support system. This may have caused a deviation in the results. At the same time, whether the technical differences of surgeons in this project, or the inability to achieve absolute homogeneity in perioperative management, or the initiative of patients may affect the results of this study. Therefore, these factors should be analyzed in future studies to make the results of greater clinical significance.

5. Conclusion

In this study, diversified health-promoting models were introduced to provide guidance on postoperative rehabilitation exercises for CSM patients. This can improve the patients’ self-efficacy management ability in term of rehabilitation exercises, help them enhance their grip strength, promote the recovery of cervical spine function, and increase their postoperative comfort level, thereby improving their quality of life.

Funding

The study was funded by Fujian Medical University Union Hospital (2022YYZDXK01).

Competing interests

The authors declare that they have no competing interests.

Ethics statement

This study was approved by the Ethics Committee of Fujian Medical University Union Hospital (Approval No.: 2020YF34-01). This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.

Data availability statement

The data used to support the findings of this study are available from the corresponding author upon reasonable request.

Footnotes

Acknowledgments

We would like to acknowledge the hard and dedicated work of all staff that implemented the intervention and evaluation components of the study.

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Application effect of diversified health-promoting models on rehabilitation exercises for cervical spondylotic myelopathy

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Subjects and methods

2.1 Subjects

2.3.1 Self-efficacy rehabilitation outcome (SER) scale

2.3.2 Measurement of grip strength

2.3.3 Japanese Orthopaedic Association (JOA) cervical vertebra scale [27]

2.3.4 Evaluation of activities in daily life

2.4 Evaluation timing

2.5 Quality control

2.6 Data processing

3. Results

3.1 Analysis and comparison of the demographics between the two groups

Table 1 Comparison of demographics between two groups ( n , %, x ± s)

Table 2 Comparison of self-efficacy assessment for rehabilitation outcome between two groups (X ± S, score)

4.1 Diversified health promotion models help improve patients’ self-management abilities of rehabilitation exercises

4.2 The diversified health-promoting models help improve the patients’ grip strength and promote the functional recovery of cervical vertebra

4.3 Diversified health-promoting models can improve patients’ activities in daily life and their quality of life

4.4 Limitations

5. Conclusion

Funding

Competing interests

Ethics statement

Data availability statement

Footnotes

Acknowledgments

References

Table 1
Comparison of demographics between two groups ( $n$ , %, x $\pm$ s)

Table 2
Comparison of self-efficacy assessment for rehabilitation outcome between two groups (X $\pm$ S, score)