Orthotic management of spinal conditions presents a variety of options and challenges to today’s clinicians…options in the wide variety of devices now in use, challenges in selecting the most appropriate one for each patient’s specific needs.
Spinal bracing encompasses three primary objectives:
- Control of back pain, by limiting motion and unloading discs, vertebrae and other spinal structures through abdominal compression.
- Temporary stabilization of weak or injured structures, as in spinal immobilization following back surgery, or protection for injured ligaments or muscles.
- Long-term protection, control or correction of a spinal deformity by application of three-point force systems. In children with scoliosis or another spinal deformity, the orthosis is employed to provide partial correction or prevent progression of a deformity (scoliosis, hyper- or hypolordosis, or hyper- or hypokyphosis) during completion of growth and spine maturation.
Virtually all spinal orthoses achieve these objectives by three effects: (1) abdominal compression, (2) restricted trunk motion, and (3) a three-point force system to effect modification or partial correction of a spinal deformity.
How effective are spinal braces at achieving these objectives?
Investigators generally agree that a well-fitting orthosis offers effective control of gross spinal motion, but its ability to control intersegmental vertebral motion is not as well accepted. Certainly a brace custom fabricated to a positive model of the patient’s anatomy offers the greatest opportunity for success in this regard. However, newer off-the-shelf appliances are becoming increasingly adaptable with many more customization features than older models and thus offer more potential for a successful outcome.
Spinal orthoses are broadly categorized as flexible, rigid, or semi-rigid. Flexible orthoses consist primarily of cloth belts and corsets. Thanks to innovative application of resilient plastics in the last decade, semi-rigid devices combine the strength and support of traditional rigid materials with the comfort and improved tolerance of fabrics.
Flexible belts and corsets are prescribed for relief of low back pain associated with degenerative disc disorders, trauma or postural fatigue and, in certain cases, to provide a measure of biomechanical stabilization. They are typically made of cotton, nylon or rayon fabric. Corsets serve primarily to unweight spinal structures by increasing abdominal compression. Adding rigid inserts and/or vertical stays can effectively restrict motion, either by physical limitation or as a reminder to maintain proper posture. Sacroiliac belts and corsets are sometimes used for postpartum and post-traumatic stabilization of pelvic joints.
Most flexible spinal orthoses come prefabricated and are custom fitted and modified to patients’ specific requirements. While many health practitioners provide and fit these flexible devices, a certified orthotist is the most qualified and best equipped for addressing the unique needs many patients present.
Semi-rigid systems combine a high percentage of the spinal control provided by a rigid brace with the tolerance-enhancing comfort of a flexible orthosis. A new type of semi-rigid design, exemplified by the OrthoLux soft orthosis, incorporates breathable spacer fabrics laminated between layers of foam with semi-rigid moldable panels sewn into anterior and posterior pockets.
A well-trained orthotist’s skill and experience is of particular importance in the initial fitting of and progressive adjustments to rigid deformity braces and in providing custom-fabricated orthoses.
Prefabricated Orthotic Braces
Among the significant prefab braces:
- Flexion-extension control braces employ one or more three-point force systems to limit flexion and extension, limit rotation to a small degree and somewhat limit lateral bending and increase abdominal compression. Notable examples include the “chairback” LSO and Taylor TLSO, which may be prescribed for relief of low back pain and immobilization after back surgery.
- Flexion-extension-lateral control orthoses, such as the Knight LSO and Knight-Taylor TLSO, as the name implies, provides motion restriction for flexion, extension and lateral movement but minimal rotation control.
- Anterior hyperextension (flexion control) TLSOs apply a three-point force system to restrict forward flexion in the thoraco-lumbar area to counter hyperkyphosis and increase lumbar lordosis, frequent needs of patients with osteoporosis, and to provide support after spinal fractures. Commonly used models include the Jewett and CASH braces.
- Thermoplastic modular TLSOs, such as the Boston Overlap Brace, are typically manufactured in standard sizes and different curvature contours.
With proper fitting, these orthoses have proven effective for treating back injuries, as well as discogenic low back pain and various deformities.
While properly fitted prefabricated systems can be used successfully in a variety of applications, the greatest degree of control is obtained with a custom-molded body jacket.
A body jacket constructed of high-temperature thermoplastic applies firm counter force to spinal motion is all planes (flexion-extension, lateral and rotation) and elevates abdominal pressures. Because a properly molded jacket achieves total contact, pressures are distributed over the widest possible area, increasing patient comfort and compliance.
Recent improvements include frontal closures for easier donning and doffing, use of lightweight plastics, use of multiple cutouts to accommodate individual patients’ anatomy and improve air circulation, and modern fabrics to wick moisture away from the skin. Unfortunately, not all patients who require the definitive support and/or correction of a rigid body jacket can begin to tolerate one:
Common geriatric complications – reduced muscle tone, skin conditions, and scar tissue – often render a rigid orthosis unusable. In the past, these patients typically have been given a soft dorsolumbar support, which while effective in mild cases is usually not sufficient to enable patients with advanced deformity to resume a reasonable level of daily activities.
Today, an increasingly common approach is a soft body jacket. This orthosis maintains the total body contact provided by its rigid cousin, dispersing the corrective force over as wide an area as possible. Also like the hard jacket, it is custom-molded to a model of the patient’s torso, but in place of the rigid, heavy thermoplastic shell, the soft version is constructed of lightweight plastic and soft inner foam, which combine to make the jacket substantially more comfortable to don and wear and easier to tolerate for extended periods. The challenge is to incorporate the most rigid materials possible and still promote compliance.
The soft body jacket is applicable for geriatric patients requiring external support for long-term spinal problems: osteoporosis, compression fractures and deformities of other origins.
Management of adolescent idiopathic scoliosis with a spinal bracing regimen continues to spark debate within the medical community. Proponents note that while permanent improvement of scoliotic spinal curvature is uncommon as a sole result of bracing, this modality has been proven effective at preventing further progression of abnormal curves until the patient achieves skeletal maturity.
Options range from the time honored, though sometimes compliance-challenged, Milwaukee Brace CTLSO to the less-conspicuous Boston Brace TLSO to the nocturnal Charleston Bending Brace and Providence Scoliosis System, which operate under the principle that providing a more-rigorous corrective force over shorter periods, i.e. at night, will achieve desired spinal curve change while giving the wearer more freedom and a stronger self-image.
While several different braces discussed in this article may be applicable to a given patient’s needs, regional and individual preferences often dictate prescription decisions. Our qualified orthotic practitioners are readily available to discuss your patients’ requirements and assist you in choosing the most appropriate spinal orthosis for their specific requirements.
Call our office any time you require assistance. We have offices conveniently located in Beaumont, Nederland and Jasper, Texas.