Terminology Orthosis: A singular device used to aid or align a weakened body part Orthoses: Two or more devices used to aid or align a weakened body part Orthotics: The field of study of orthoses and their management Orthotic: An adjective used to describe a device Orthotist: A person trained in the proper fit and fabrication of orthoses
Prescription: Prescriptions should include the following items: Patients name, age, and gender, Current date Diagnosis Functional Goal, Orthotic description Area covered Flexible or Rigid device Custom or Off-the-shelf Control desired based upon biomechanics of the spine Restriction of sagittal plane motion Restriction of coronal plane motion Restriction of transverse plane motion
Precautions Physician name and unique physician identifier number Physician signature, office address, contact phone number.
Objective of Spinal Orthoses
Control of Pain limiting motion or weight bearing Provides heat to an area
Protection against further injury
Limits motion Promotion of healing of fractures
Stabilization of vertebral segment
Provides stabilization when soft tissue cannot
Assistance for muscle weakness
Serves as a kinesthetic reminder
Purpose of Spinal Orthoses
Prevention and Correction of Deformities
By providing external forces
Applying corrective forces to abnormal curvatures 3-point pressure system
Reduction of Axial Loading
Morris,1961 JBJS
Elevated intra-abdominal pressure
Reduces the net force applied to spine during the act of lifting a weight from the floor Reduces intradiscal pressure approximately 30% in lumbar spine
Postsurgical Stabilization With or without fracture
John Redford ,PM&R secrets Chapter 96
Ideal Orthosis Functional Fits well Light in weight Easy to use Cosmetically acceptable Easily maintained/repaired Ideally locally manufactured Different than the 3Hspredicing failure Hot, heavy, horrible looking
Custom vs Off-the-shelf Tenet of Orthotic classical practice Customized orthoses more effectively limit or control motion better than prefabricated or off-the-shelf orthoses
More intimate fit with custom
Better control of Triplanar Motion with custom Better control of lateral flexion and Rotation with custom Unequal panels from OTS that creates flexion or extension components Rotation not controlled in OTS due to not locking down on ASIS or the rib cage Custom better adjustment for pendulous abdomen Custom more comfortable to wear than OTS Bernardoni: Comparison between custom and noncustom spinal orthoses: PM&R Clinic NA 12(2006)73-89
Nomenclature/Categories Name by the body regions that Rigidity they cross/ Eponyms CO: Cervical Orthosis Rigid Soft or rigid (Philadelphia, Aspen, Miami, Newport) Semirigid CTO: Cervicothoracic orthosis Halo, SOMI, Minerva Flexible CTLSO: Cervicothoracolumbosacral orthosis Milwaukee
TLSO: Thoracolumbosacral orthosis
Custom-molded body jacket, CASH, Jewett
LSO: Lumbosacral orthosis
Chairback, Knight, corsets/binders
SO: Sacral orthosis
Trochanteric belt, sacral belt, sacral corset
Types
Halo SOMI Cervical Collar (Miami-J) CTO TLSO with proximal extension TLSO TLSO with leg extension Chairback
Lumbar spine Major motion is flexion/extension Small degree of sidebending and very little rotation
Thoracolumbar Junction (T12-L1)
Most mobile section of the spine
Midlumbar (L2-4) Lumbosacral Junction (L5-S1) Area more difficult to control
Range of Motion Spinal Area
Braddom 3rd edition
Soft Cervical Collar
Foam Rubber Benefit Warmth Psychological Reassurance Kinesthetic reminder to limit motion No structural support May not reduce duration of intensity of pain Flexion/Ext limited 5-15% Lateral Bending limited 5-10% Rotation limited 10-17%
Miami J Collar Polyethylene
Has tracheostomy opening
Custom adjustment around chin and occiput Lowest level of mandibular and occipital tissue-interface pressure compared to other rigid COs Lower skin temperature Less sweating Less skin breakdown
Indications
s/p Anterior Cervical fusion
Jeffersons Fx (C1) Hangmans fracture
Flexion/Ext limited 55-75%
Lateral Bending limited 60% Rotation limited 70%
Traumatic spondylolisthesis of C2 on C3
Dens type I fracture
Anterior diskectomy Cervical trauma in unconscious patients Cervical Strain
Malibu Collar 2-piece orthosis Anterior opening for tracheostomy Adjustable chin support
Indications
s/p Anterior Cervical fusion
Dens type I fracture Anterior diskectomy Cervical trauma in unconscious patients Cervical Strain Flexion/Ext limited 55-60% Lateral Bending limited 60% Rotation limited 60%
Use of CO for Axial Neck
Pain No evidence for rigid or soft CO Only thing beneficial is therapeutic exercise In whiplash injury could prolong return to work 34 days vs. 17 days (p<0.05)
Crawford, Early Management and outcome following soft tissue injury of the neck: A random controlled trial Injury: 2004;35 (9) 891-895
Philadelphia Collar with Thoracic
Extension 2-piece Plastizote Foam High capillary closing pressure
CTO CTOs provide significantly more restriction of intervertebral flexion and extension than COs Controls motion down to around T5
Halo Device 4-Poster Control Controls down to T3 Usually worn 8-12 weeks Good control Occiput to C1 Poor control midcervical region Flexion/Ext limited 65-70% Lateral Bending limited 30-35% Rotation limited 60-65%
Halo Device Positioning
Anteriorly 1cm above orbital rim lateral orbit
Posteriorly 1 cm above the top of the ear/below largest diameter of skull
Halo Device Problem
Intersegmental snaking
Flexion of one vertebral
segment with extension of the adjacent vertebral body Koch + Nichel:31% of normal motion at lower cervical level (C4-5) Lind: 2-17 C2-C6 Most OA
Lighter than halo No pins No risk of infection or slippage
Less restriction than Halo for OA
Better control intersegmental than Halo Indication
Unstable cervical spine
Compliant patient Patient with skull Fx Preschool children Decrease weight Increase comfort
Alterative to Halo/Minerva Lerman noninvasive halo system Use in children
Orthosis
Mean of normal motion (%)
Flexion or extension
Lateral bending
Rotation
Normala
100.0
100.0
100.0
Soft collara
74.2
92.3
82.6
Philadelphia collar
28.9
66.4
43.7
Sternal occipital mandibular immobilizer brace
27.7
65.6
33.6
Four-poster brace
20.6
45.9
27.1
Yale cervicothoracic brace
12.8
50.5
18.2
Halo devicea
4.0
4.0
1.0
Halo deviceb
11.7
8.4
2.4
Minerva body jacketc
14.0
15.5
Braddom 3rd edition
Efficacy of Cervical Orthoses
Agabegi: Spinal Orthoses JAAOS, November 2010, Vol 18,#11
Summary Best CO All orthoses tend to control flexion better than extension Increasing height of the rigid collar more restricted motion
May also lead to increase cervical
extension (?undesirable)
The halo is the most effective
orthosis for use in controlling flexion and extension at C1-C3, followed by the 4-poster brace and then the CTOs CTOs are best for use in controlling flexion and extension at C3-T1, whereas the SOMI is best for use in controlling flexion at C1-C5
The CTO brace is the second
best orthosis for use in controlling rotation and lateral bending in the cervical spine The SOMI controls extension less effectively than do other orthoses The halo is the best orthosis for use in controlling rotation and lateral bending at C1-C3 The 4-poster (Halo) brace is slightly better than the CTO brace for use in controlling lateral bending in the cervical spine
Summary Best CO Miami J Collar Lowest level of mandibular and occipital tissue-interface pressure compare to other COs
Cervical Collars Increase intracranial Pressure in TBI Swallowing effected Narrowing of Pharynx Extension or Hyperextension of Cspine
Rigid CO Less control Occiput to C2 C6-7
Good control Mid cervical (better than Halo)
Philadelphia Collar Not well ventilated Increased skin maceration
Increased pressure on chin, mandible, occiput Increased risk of tissue ischemia and ulcer
All patients remained neurologically intact Braces/Casts avoid surgical complications Operative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003
T/L Burst Fractures without Neurological
Deficit: RCT Op vs. Brace N=80 Op: Posterior 3-level fixation earlier pain relief and partial kyphosis correction (gradually lost) Earlier pain relief
Non-op: Hyperextension brace
FUNCTIONAL OUTCOME AT 2 YEARS SIMILAR
Safe treating burst fx with TLSO*
Li-Yang Dai: Conservative Treatment of Thoracolumbar Burst Fracture: Spine Vol 33, No 23 pg 2536-2544 2008* Nonoperative Treatment vs. Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurological Deficit. Shen et al. Spine 2001
Compression Fractures (<30%):
Bracing vs. No external support T12-L5; Mostly L1 One-column fractures of the thoracolumbar spine with <30% compression can be treated with early ambulation and hyperextension exercises Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000
Flexion Control
Cruciform Anterior Spinal
Hyperextension Brace (CASH) Flexion control
Does not limit lateral bending or
rotation Easy to donn/doff
Indications
Thoracic/lumbar vertebral body
Fx Kyphosis reduction/osteoporosis
Contraindication
Unstable Fracture Where extension is prohibited
Flexion/Extension limit T6-L1
Can cause excessive
hyperextension forces of the posterior elements
Jewett Hyperextension Brace
Flexion control
Does not limit lateral bending or
rotation
Indications(T6-L1)
Thoracic/lumbar vertebral body
Fx Kyphosis reduction/osteoporosis Post op stabilization of TL Fx
Contraindication
Unstable Fracture
3-column fractures
Compression Fx above T6
Increased motion above pad
Flexion/Extension limit T6-L1
Where extension is prohibited
Can cause excessive hyperextension forces of the posterior elements
Flexion-Extension Control
Taylor Brace Limited motion of Mid to lower thoracic to upper lumbar region Increase motion Upper thoracic and lower lumbar & LS junction
Flexion-Extension-lateral Control
Knight-Taylor TLSO Limits flexion,extension and lateral bending Poor rotary control More of scapular band than Taylor
Indication Thoracic and lumbar compression Fx Post-op and nonsurgical management of stable thoracic or lumbar fxs Arthritis Spinal weakness
Flexion-Extension-Lateral-Rotary Control
Custom-Molded Body Jacket
Polypropylene or Plastic Best control all planes Increases intracavity pressure Diffuse distribution of pressures Ideal for Neurologic Injuries Reduces myoelectric activity of erector spinae muscles
T3-L3 areas Anterior shell inch above pubic symphysis to sternal notch
Posterior shell Spine of scapula to sacrococygeal junction
Lumbosacral Orthoses (LSO) Flexible or Rigid
Elevated intra-abdominal pressure reduces net force
applied spine during the act of lifting a weight from floor Morris: JBJS, 1961;43:327-351
Tight brace can reduce intradiscal Pressure in lumbar
spine by 30% Nachemson, JBJS,1964;46:1077-1092
Variable Effect on myoelectric activity of abdominal
muscles/Extensors of spine Lantz,Spine Vol(11),No 8 1986 838-842
No benefit for Low back pain
Consensus statement APTA Guidelines LBP 2012
Flexible LSO Corsets or binders Indications Pain relief Postural support Vasomotor support SCI
Respiratory Support SCI
Flexion-Extension Control Sagittal Plane Limits FlexionExtension L1-L4 Minimal limitation of rotation Lateral bending by 45% Chairback
Unloads intervertebral disc
Chairback LSO Sagittal Plane
Paraspinal bars Butterfly pelvic band Sacrococcygeal junction
Thoracic band Below inferior angle of scapula
Abdominal support Tightening the abdominal support creates intra-abdominal pressure, which effectively reduces lordosis in the lumbar spine
Indications
Lower back weakness or pain
Sacroiliac pain Arthritis s/p Lumbar laminectomy
Extension-Lateral Control
Williams Flexion LSO
Sagittal and Coronal Plane Control Components
Pelvic band Thoracic band Lateral uprights Pivotable attachments No posterior upright
Indications: Creates Lumbosacral flexion Includes extensor activity of hip and spine Relieves postural imbalance in low back pathologies with lordosis Spondylolysis Spondylolisthesis
Paraspinal bars Lateral uprights Pelvic band Thoracic band Abdominal support Tightening the abdominal support
Indications: Lower back weakness or pain,Arthritis,Need for immobilization of the lumbosacral region
creates intra-abdominal pressure
which effectively reduces lordosis by distending the lumbar spine.
Custom-molded,plastic LSO
Orthotic Treatment Compression Fracture Only 2 Orthotics scientifically studied for efficacy: Spinomed-activates back muscles to straighten the dorsal spine and decrease kyphosis to treat chronic VCFs
http://www.spsco.com/press/07-12-06c.html Pfeifer M, AJPMR 2004
Lantz and Schultz, Spine 1986 Increase electrical activity of back muscles when LSO worn Principle effect may be a biofeedback mechanism
Pfeifer M, AJPMR 2004
Females with one clinical vertebral fracture caused by osteoporosis and an angle of kyphosis of 60 degrees as measured by stereophotomorphometry. Noted: Significant increase in trunk muscle strength Increase muscular activity while wearing the LSO
Spino-Med by Pfeifer
Wearing the orthosis for 6-mo period, 2 hours per day
73% increase in back extensor strength
58% increase in abdominal flexor strength
11% decrease in angle of kyphosis 25% decrease in body sway 7% increase in vital capacity 38% decrease in average pain 15% increase in well-being 27% decrease in limitations of daily living.
Overall tolerability of the orthosis was good
no side-effects were reported drop-out rate of 3% was rather low.
Rucksack Orthosis for
Osteoporosis (PTS)
Characteristic postures arising from
weakened back muscles and improved walking posture with rucksack spinal orthosis
Postural Training Support(PTS) Encourages back extension through the addition of weights Limits flexion Posterior pocket holds 2 lb weight Allows progressive build up of weight
Adjustable straps to accommodate fitting
Sizing done by shoulder measurement Weights made of vinyl with steel fillers Velcro closure for easy donning/doffing
Spinal Orthosis by Segment
Scoliosis Orthoses
TLSOs: Accommodative and Corrective
Accommodative TLSO Fabricated of soft pelite Reinforced with Kydex or rigid plastic
Ambulatory and non-ambulatory patients Fixed alignments
Accommodative TLSO Maintain head and trunk over pelvis
Level shoulders Reduce or minimize shear forces Allows patient to increase upper extremity use or decrease dependence
Accommodative TLSO Key to good positioning! Enhances mobility base Assists patients with pulmonary compromise Used with fixed position wheelchair, tilt in space, or molded seats
Idiopathic Scoliosis Milwaukee-style CTLSO
Biomechanic in Scoliosis Large curves are more readily straightened by elongation Smaller curves are more readily straightened by application of lateral forces Usually placing pad below the apex causing lifting force
Supine more effective force of TLSO than upright
Key to using bracing at night
Elongation of curve Reducing lumbar lordosis more effective in treating scoliosis in lumbar and thoracic spine Reduction of the lumbar lordotic curve at the expense of flattening the thoracic kyphotic curve ( may be problem) Correct coronal plane motion but much less 3-D motion
Watts, Bracing in Spinal Deformities 1979
Corrective TLSO
Progressive correction of idiopathic spinal
curvatures Supple curves (20-40) 20-30 observe initially, if curve progresses by 5 then brace 30-40 prompt use of orthosis 40-50 requires surgery, but orthoses may retard progression long enough to allow further trunk growth prior to fusion Indicated Risser <2
Stabilization of congenital spinal curvatures
Prevention of progression Usually same curve beginning and end of use
Moe + Winter purpose of bracing is to keep small curves from
getting bigger, not to make big curves smaller
Used full-time 16-20 hrs/day until skeletal maturity -Optimum is 23 hrs/day
Risser Sign:
Apophysis closes from anterior to posterior
Spinal Orthotics in Scoliosis
Curves w/ apices T-8 or lower may be treated w/ underarm braces
Wilmington brace (custom
made) Boston brace (prefabricated)
High thoracic curves
may require the Milwaukee Brace
Metal vertical suprastructure with pelvic
foundation
Milwaukee Brace
Boston
Charleston Brace Prescribed for parttime wear, usually 8 hours at night Is designed to unbend the scoliotic curve Few long-term follow-up studies
Boston vs. Charleston
Katz: 1996
compared the effectiveness of the TLSO Boston brace
versus the TLSO Charleston brace Both were statistically comparable in preventing curve progression and surgery in single curves of 25-35 Boston brace was more effective in treating curves 36-45 and multiple curves
Watts 1977
Boston not use if apex above T10 or curves greater than
40
Scoliosis Orthoses
Weaning from TLSO in
Scoliosis Slow wean is the best Want no loss of correction up to 3 degrees
Off 2 h/day then Repeat X-ray 3 months
Off 4 h/day then repeat X-ray 3 months Off 8 h/day then repeat X-ray 3 months Off 12h/day then repeat X-ray 3 months Use TSLO night only for minimum of 1 year
Orthotics for Spinal Deformity, Robert Winter: Clinical Orthopaedics & Related Research No:102, JulyAugust 1974 pg 72-91
Bibliography Kulkarni, Shantanu: Spinal Orthotics,http://emedicine.medscape.com/article/314921, Aug 25, 2008 Bernardoni: Comparison of Custom and noncustom Spinal Orthoses, Phys Med Rehabil Clin N Am ,17 (2006) 7389 Lantz SA, Schultz AB: Lumbar spine orthoses wearing: Effect on trunk muscle myoelectric activity. Spine 1986;11:8384234. Pfeifer M, Begerow B, Minne HW: Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: A randomized trial. Am J Phys Med Rehabil 2004;83:177186.
Bibliography Pomerantz,F: Chapter 62 Spinal Orthotic, Delisa Physical Medicine & Rehabilitation, Principles and Practice 4th ed, 2005 pg 13551365 Cuccurulo: Physical Medicine and Rehabilitation Board Review: 2005 Katz DE, Richards BS, et al. A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis. Spine 1997; 22:1302-1312.
Bibliography Orthoses for Spinal Conditions-Clnical Decision Making, Chapter 17; Prosthetics and Orthotics, Seymore pg 427-447 Bernardoni: Comparison between custom and noncustom spinal orthoses: PM&R Clinic NA 12(2006)73-89 Li-Yang Dai: Conservative Treatment of Thoracolumbar Burst Fracture: Spine Vol 33, No 23 pg 2536-2544 2008
Bibliography Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000 H.G. Watts, Boston Brace system for the treatment of low thoracic and lumbar scoliosis by use of girdle without suprastructure; Clinical Orthopaedics and Related Research, No 126, July-August 1977 Agabegi :Spinal Orthoses, J. Am Acad Orthop Surg, 2010;18:657-667 Watts H.G, Bracing in spinal deformities. Orthop Clin North Am, 1979, Oct, 10(4):769-785
