Injury 54 (2023) 110986

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Thoraco-lumbar-sacral orthoses in older people – A narrative

literature review
Surabhi Varma 1, Kevin Tsang, George Peck *
Major Trauma Center, St. Mary’s hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, U.K

A R T I C L E I N F O A B S T R A C T

Keywords: Fractures in the thoracolumbar region have a bimodal distribution, with an increasing number of older people
Elderly trauma presenting with acute vertebral fractures after atraumatic or low energy mechanisms of injury.
Thoracolumbar orthoses In the absence of neurological compromise and significant vertebral instability, thoracolumbar fractures are
Vertebral fracture
often managed conservatively and bracing is widely recommended. However, in older cohorts, bracing is often ill
fitting and poorly tolerated with non-compliance leading to prolonged immobilization. Systematic reviews and
meta-analyses have challenged the motive of bracing, but as evidence quality is low, the role of exploratory
analysis has been limited. This descriptive review summarises and examines the current evidence that underpins
the use of spinal orthoses, specific to older patients, in an effort to streamline its judicious use in clinical practice
and identify scope to direct further research.

Introduction tactile and proprioceptive input to facilitate balance. Improved fracture

healing, reduced pain and early ambulation are other intuitive benefits
The ageing spinal column has an inherent biomechanical fragility of external thoracolumbar support, but the evidence base remains
characterised by reduced bone quality and bone mineral density, controversial, particularly in older adults.
degenerative changes with spinal canal narrowing, dehydration of discs There are three main types of thoracolumbosacral orthoses (TLSOs).
causing stress shielding and reduced elasticity and strength of stabilizing The traditional rigid TLSOs such as Jewett brace or Knight-Taylor brace
ligaments [1,2]. Subsequently, older people have an increased pro­ provide more rigid stabilization but are poorly tolerated and may lead to
pensity to vertebral fractures and spinal cord injury even with low en­ para-spinal muscle atrophy [4,5]. Custom or off-the-shelf semi-rigid
ergy mechanism of injury [1]. Surgical intervention is less frequent in TLSOs are less rigid alternatives when severe spinal restrictions are not
older cohorts largely due to the nature of injury, the presence of indicated. Spinal dynamic orthoses (SDO) are less restrictive braces with
comorbidities and structural changes of the ageing spine [3]. In patients a primary role in biofeedback activation of spinal muscles [6]. They
where surgical management is not indicated or suitable, conservative compliment physical training but offer little benefit in mechanical
management of thoracolumbar fractures has evolved from traditional immobilization.
prescription of prolonged bed rest, to promotion of early ambulation- Many perceive that orthoses are particularly poorly tolerated in older
often supported by the use of stabilizing orthoses. patients, but they continue to be commonly used in clinical practice. In
The hypothesis is that external bracing reduces gross spinal motion the absence of robust clinical trials, the role of systematic analyses is
and applies pressure along the sagittal plane to maintain neutral spinal limited. This narrative review summarises current knowledge around
alignment and prevent neurological and morphological instability. the use of TLSOs in vertebral fractures, specific to older adults. It aims to
Reduced anterior load on the vertebral column through intra-abdominal understand the advantages they offer, misperceptions in current practice
compression is thought to reduce kyphotic deformity, which is consid­ and disparities between empirical practice and state of evidence.
ered to be the main cause of longer-term pain and disability. It provides

Funding: Open access fee provided by Cutrale Perioperative Ageing Group

* Corresponding author at: Department of Medicine for the Elderly, Mary Stanford Wing, St Mary’s hospital, Praed Street, London W2 1NY, UK.
E-mail address: [email protected] (G. Peck).
1
Permanent address for Surabhi Varma: West Middlesex University Hospital, Chelsea & Westminster NHS Foundation Trust, Twickenham Road, Isleworth, TW7
6AF, U.K

https://doi.org/10.1016/j.injury.2023.110986
Accepted 5 August 2023
Available online 9 August 2023
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Varma et al. Injury 54 (2023) 110986

Methods bracing in the context of peri‑operative intervention, kyphoplasty,

vertebroplasty and other indications unrelated to fractures, were
We conducted a literature search using PubMed database (Fig. 1) on excluded. We excluded publications that considered taping and casting
7th May 2023. The search strategy was kept broad to include grey as orthotic interventions. Two authors screened titles and abstracts,
literature and employed keywords, titles, abstracts and medical subject distilling 176 citations that warranted full text evaluation. References
headings (see Fig. 2 for syntax). This resulted in 1161 citations. Inclusion were searched and 2 additional studies were identified. 44 published
criteria were i) articles published between January 2000 and April 2023 articles have been considered in this literature review [6–49].
ii) articles published in English iii) for primary research studies, the These have been examined to appraise the impact of bracing on
mean age of subjects where stated was above 60 years. Studies exam­ spinal alignment, gait and postural stability, pain and functional well­
ining vertebral osteoporosis were included if they recruited at least some being, pulmonary function, bone density, compliance, adverse events
patients with vertebral fractures. However, articles that evaluated including delirium and cost-effectiveness.

Fig. 1. PRISMA flowchart.

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S. Varma et al. Injury 54 (2023) 110986

Fig. 2. Search syntax.

Results balance, demonstrating continued reduction in trunk motion by 8% at 6

weeks. The benefit was observed even when the brace was removed, but
Kyphotic deformity diminished by 6 months. Observed benefits of bracing on walking speed,
stride length and cadence over 6 months cannot be differentiated from
2 studies demonstrated an increase in angle of kyphosis with use of the effect of natural fracture healing. There was no significant
rigid and customized TLSOs in acute vertebral fractures [7,8]. However, improvement in the margin of stability [14].
in the absence of a control arm, these findings are at best hypothesis Whether the indeterminate effects on static balance and stride
generating, as the effect of natural fracture ageing cannot be differen­ impact the overall risk of falls and physical activity in the acute phase
tiated from the impact of bracing. remains unevaluated.
Conversely, in sub-acute fractures, Pfeifer et al. demonstrated mean
reduction in angle of kyphosis by 7.9◦ in patients who wore semi-rigid
Spinomed orthosis and 8.1◦ in patients wearing spinomed active Pain
orthosis (p<0.01) for 6 months [9]. In comparison, unbraced controls
had a mean reduction of 1.6◦ but upon cross over to intervention group, TLSOs are commonly prescribed for pain management, to facilitate
a significant reduction in kyphotic angle was again observed after 6 early mobility and optimize functional performance. However, much of
months. One way crossover renders intention-to-treat analysis invalid the evidence base has emerged from observational data with no
and the conclusion may be biased . Other studies did not show similar unbraced comparison [7,13,14,18,19].
results with bracing although this could also be attributable to chro­ We identified four studies that compared orthosis groups to controls
nicity of fractures, different parameters to define kyphotic deformity [9,11,15,20].
and a small sample size [10,11]. Kaijser et al. showed no significant difference in visual analogue
There are no studies that compare different types of orthoses on their scale (VAS) and Borg CR10 pain outcomes with orthosis application
effect on kyphotic deformity. when compared with unbraced controls or those prescribed exercise
training [11]. In contrast, a study showed that 6 months of Spinomed
Other radiological parameters of spinal deformity reduced VAS by 37% (41±17.3 vs 65± 16.5, p = 0.001) from baseline
compared to non-intervention group (45± 16.5 vs 45±16.5) [20].
Anterior vertebral body compression percentage (AVBCP) is the ratio Pfeifer et al. demonstrated a statistically significant reduction in the
of the anterior vertebral height to the posterior aspect of the same 4-point Milner pain score in the braced group (− 1.5 ± 1.2, p < 0.02)
vertebra. Rigid bracing has shown a more favourable AVBCP compared compared to the unbraced group (+0.1 ± 0.9), but treatment efficacy
to soft bracing after 12 weeks of application (58.5 vs 54.6, p = 0.04), but remains dubious given the small change in pain reduction [9]. The
this difference did not reach statistical difference at 48 weeks [13]. possibility of bias in using a subjective, uni-dimensional outcome mea­
Similarly, a small observational study showed beneficial reduction in sure needs to be considered [9,11,15,20]. Importantly, these studies did
global sagittal alignment (48.3 + 7.64 vs 54.6 ± 8.49, p = 0.001) with not include acute fractures.
application of a semi-rigid orthosis after 6 weeks, but this rebounded to Kim et al. more robustly examined the use of opioids, alongside VAS
baseline (52.60 + 9.84) at 6 months [14]. in acute single-level compression vertebral fractures, to conclude that
Only one study included an unbraced control group. It did not there was no difference in back pain at 3 months between the unbraced,
demonstrate any difference in the anterior vertebral body height loss soft-braced and rigid-braced groups [15]. In fact, opioid use at 12 weeks
between unbraced, soft-braced and rigid -braced groups after 12 weeks was lowest in the unbraced group (17.6%) compared to the soft-braced
(p = 0.237) [15]. (20%) or rigid-braced (23%) groups.
Dynamic mobility is the difference in anterior vertebral height in
upright and supine positions. Its persistence may be prognostic of non-
union and pain [16]. TLSOs have been shown to successfully achieve Other quality of life measures
loss of dynamic mobility in 88.7%- 94% of patients at 6 months, but
causality cannot be inferred due to absence of non-intervention group Only two studies included unbraced comparison group. Pfeiffer et al.
[7,12]. demonstrated an improvement in Bergrow’s well-being score in non-
acute vertebral fractures treated with Spinomed (+10.4 ± 7.9,
Postural stability & gait p<0.01) and Spinomed active (+10.7 ± 8.2, p<0.01) but a decrease of
2.3 ± 3 in the unbraced group [9]. The same trend extended to LDL
Computed dynamic posturography in osteoporotic vertebral frac­ disability and LDL self –care scores [9]. A study involving acute verte­
tures demonstrated improved average postural stability with Knight- bral fractures contradicted these findings [15]. No-brace group was
Taylor brace on (68.3 + 8.5% vs. 63.6 + 10.5%, p = 0.001), due to non-inferior to soft and rigid braced groups in Oswestry Disability Index
beneficial influence on some metrics of static balance [17]. However, (35.9 vs 37.8 vs 33.54, p = 0.260) and SF36 physical (p = 0.716) and
the average directional control was reduced and on-axis velocity on mental (p = 0.889) wellbeing assessments.
left/right rhythmic weight shift was higher, suggesting that bracing may Qualitative data suggests that bracing contributes to a sense of sup­
negatively impact dynamic balance. port, security and improved ability to perform daily activities [18,21].
Jacobs et al. demonstrated that wearing an orthosis decreases trunk Studies have demonstrated better multi-dimensional functional
motion (2.38 cm+2.84 vs 3.60 cm+ 3.69 p = 0.006), allowing a more assessment scores with SDOs compared to rigid or semi-rigid braces [10,
upright posture [14]. It looked at the longitudinal effects of bracing on 12,22].

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Muscle strength orthoses by facilitating early ambulation [51]. However, in clinical

practice, cognitive impairment is an important barrier to brace
It has been postulated that the use of external support may exacer­ compliance. It is also known that physical restraints are associated with
bate para-spinal atrophy. This has largely been extrapolated from development of delirium. None of the studies we identified examined
anthropometric indicators on healthy volunteers and we did not cite any the association of bracing and cognitive outcomes.
recent clinical studies to demonstrate that bracing adversely affects One study has demonstrated that there was no association between
para-spinal bulk in vertebral fractures [4,5,49]. the type of brace and the mini-mental state examination at 6 months
SDOs have been shown to improve strength of spinal extensors and [25].
abdominal flexors in vertebral fractures compared to controls [9,11,12,
19,20]. A randomized control trial showed a 29% increase in back Pulmonary function
extensor strength with SDO compared to 9.9% without orthoses. How­
ever, the increase with exercise training alone was 22.1% and was not Studies in juvenile kypho-scoliosis suggest that bracing may reduce
statistically different compared to SDOs [11]. pulmonary function due to restrictive effects on the thoracic cage [52,
None of our included studies examined the effect of rigid or semi- 53]. Ageing is associated with reduction in lung compliance, forced
rigid TLSOs on spinal strength in an older patient cohort with acute expiratory volume in 1 second (FEV1) and diaphragmatic muscle
vertebral fractures. strength. Osteoporotic vertebral fractures themselves are associated
with a two-fold increase in mortality due to pulmonary complications
Bone density [54].
3-point brace immobilization in acute fractures for two and a half
Bracing is thought to promote mechanical loading and osteogenesis. months was associated with a reduction in average FEV1 from 67.8% at
Flexible orthosis in vertebral osteoporosis showed no change in bone 7 days to 59.6% at 3 months [12]. FEV1 in SDO patients was 66.9% at 7
density after 10 weeks [18]. A weighted dynamic hyperextension brace days and 57.3% at 3 months [12]. In contrast, SDO in sub-acute fractures
worn for 12 h a day in hyper-kyphotic osteoporotic post-menopausal was associated with an increase in relaxed vital capacity (+6.1 ± 20.5%
women was associated with a mean increase in bone mineral density vs. − 9.9 ± 16.1% in unbraced controls) and FEV1 (+2.1 ± 13.5% vs.
of 23.57 mg/cm2 compared to 7.04 mg/cm2 in the control group (p = − 3.8 ± 16.1% in unbraced controls) and the differences were statisti­
0.003) after 1 year [50]. Whether this translates into any sustained cally significant [6]. The differences in the findings of the 2 studies could
reduction in vertebral fracture frequency is not known. In fact, a study be explained by the age of the fractures but also the treatment effect of
reported development of new fractures in 5.6% of patients when bracing kyphotic correction on respiratory function, as the latter study demon­
was applied to fresh vertebral fractures although causality cannot be strated significant improvement in kyphosis with bracing.
established in the absence of an unbraced control group [13].
Cost effectiveness
Compliance
The cost of a brace is estimated to be £150–220 in our National
Only one study looked primarily at patient experiences, and reported Health Services Trust, although the costs will vary in different health­
favourable adherence to dynamic orthosis due to perceived benefit in care settings [35]. Moreover, customization of TLSOs requires orthotic
maintaining good posture and improving muscle strength [21]. Another input and can take 24 to 72 h to order, which adds to bed days (esti­
study reported compliance of 66% at 6 months [20]. mated £500–800/day) and delayed ambulation [28]. Delayed ambula­
Drop out rates in trials could be auxillary indicators of compliance – tion in older patients may contribute to burden of morbidity and further
in one study, only 5 out of 92 patients in the orthoses groups dropped prolongation of in-hospital stay.
out, and in fact most continued with the treatment beyond the intended A recent meta-analysis with mean age of 39–47 years concluded that
intervention period [9]. Another large multi-centre study showed that bracing increased the average length of stay by 3.47 days [36]. This is
dropout rates were 9.3% with customized rigid TLSOs, 10.8% with probably higher in older cohorts, although no studies have looked at
customized elastic braces and 9.7% with ready- made elastic braces patient flow and health-care costs.
[25].
Stated reasons for poor compliance include worsening back pain, Discussion
difficulty putting the orthosis on and interference with urinary voiding
[8,19,20]. Our literature search included twenty-four primary studies - only six
of these had an unbraced control arm [6,9,11,15,17,25]. Only ten
Adverse effects studies looked at acute onset fractures, mostly osteoporotic compression
fractures. Only two studies in our literature search included burst frac­
Numerous complications associated with spinal bracing have been tures that are associated with higher mechanism of injury and greater
reported including pulmonary infections, decubitus ulcers, cutaneous morphological disruption [8,28]. There was considerable heterogeneity
reactions, re-fractures, urinary tract infections, gastric ulcers, ileus and in bracing conditions and outcome measures. Consequently, as evidence
inguinal hernia [7,12,13,26,27]. The frequency of these cannot be quality is poor, it is difficult to make any robust conclusions. There is
ascertained. In the absence of controlled studies, causation is difficult to significant selection bias, and many studies cannot be applied to the frail
establish and none of our identified studies looked at mortality as an older trauma population that present to hospital. Most studies excluded
outcome measure. subjects that were non-ambulatory, had other concurrent common spi­
While 2 studies have shown no difference in the types of brace and nal pathologies such as stenosis and arthritides or had cognitive
tolerability, a meta-analysis concluded that complications were highest impairment. None of the studies looked at fractures with suspected
with rigid TLSOs [4,28,29]. ligamentous or neurological instability. The role of bracing in older
patients with non-operatively managed types B and C sub-classification
Cognition of thoracolumbar fractures is beyond the scope of this review, but a
commonplace scenario void of scientific data.
Delirium is one of the most commonly encountered complications in Crucially, there is no evidence that use of rigid or semi-rigid TLSOs in
older patients with vertebral fractures [30]. It has been postulated that acute vertebral fractures improves truncal strength, kyphotic deformity,
post-operative delirium in elective spinal surgery may be reduced by pain or quality of life. There is weak evidence to suggest that compared

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