Spinal orthosis

Spinal orthosis
By
Prof.Dr. Mohammad M. Makkawy
Professor of Rheumatology & Rehabilitation
Faculty of Medicine - Zagaziy University

PRINCIPLES OF ORTHOTIC
DEVICES

 Interest in orthotics and functional aids has
increased greatly in the past few decades ,
although the indications for orthoses
remain essentially the same as in the past

 Scientific attention to improved orthotics was
initially aroused by the prevalence of
poliomyelitis.
 But with the decline of this disease, it is related
to increased numbers of patients surviving with
high spinal cord lesions and other injuries or
illness with severe paralysis due to the growth of
better systems of emergency care & expansion
of intensive care units.

 This new development is challenging
health care researchers and clinicians to
develop more effective designs of devices
that will:
# Improve function.
# Relief pain.
# Make life more bearable in the presence of
disability.

 Orthotic devices should be prescribed by a
physician since he understands the
physical condition that must be analyzed
and correlated with the device prescribed
to achieve maximum acceptance by the
disabled person. Also the prescribing
physician should be able to test muscle
strength, range of motion & evaluate all
other indications for orthotics.

 Ideally, orthotic prescription is best
accomplished by an orthotic team
consisting of physician specialized in
rehabilitation , a well-trained orthotist, a
physical and occupational therapist with
good knowledge of training procedures
required with the devices.

 The prescribing physician is responsible for:
1. Identifying treatment goals.
2. The orthotic description and any precautions
to be observed.
3. How the orthoses should be used .
4. For how long the orthoses should be used.
5. Emphasizing that the orthoses is only one
component of the treatment and not the whole
treatment.

 The fabricating orthotist should knows the
factors involved in wearing the orthoses,
such as :
Ease of application - Cosmoses - Comfort -
Durability - Need for Maintenance -
Fabrication costs and Time needed to be
fabricated.

 The physical and occupational therapists
should teach the patients proper use of the
orthoses and evaluate its adequacy, as
many orthotic devices are discarded by
patients because of inattention to this
important phase of patient education.

Prescription of Qrthotic Devices
 Good design of orthotic devices demands a
thorough knowledge of pathological anatomy
and patient requirements.
 It should be noted that biomechanical deficits
are independent of specific disease states
present. Bone & joint injuries or infections,
varying degrees of paralysis, joint diseases and
congenital deformities all have diverse causes
that may present similar biomechanical defects.
Even though the underlying disease must
always be considered in prognosis and total
management.

 Based on information obtained in the
biomechanical analysis, the anatomical
involvement is determined and the type of
orthoses required is selected. Use of the initial
letter of the English anatomical term for joints to
be included provides a useful abbreviation and
anatomical description of the type of orthoses
required. Under this system, a " long leg brace "
becomes a KAFO (knee - ankle - foot orthoses)
and a "cockup wrist splint" becomes a WHO
( wrist - hand orthoses ).

 a Orthotic clinic must be present to
organize patient management, to provide
an effective prescription, checkout and
follow- up of the patients

Indications for Orthoses
 It is important to identify the primary
purposes of an orthotic appliance. In this
respect, all orthoses are prescribed for
one or more of the following :
1. Relieve of pain by limiting motion or
weight bearing .
2. Immobilization and protection of weak ,
painful or healing musculo-skeletal
segments.

3. Reduction of axial load.
4. Prevention and correction of deformity .
5. Improvement of function.
 In many instances these goals overlap.
However in prescribing and designing
orthoses, the clinic team must always
keep primary purposes in mind and the
patient as well as his family must be
constantly reminded of them .

1-Relieve of pain by limiting motion
or weight bearing
 Musculoskeletal pain may be the result of
stretch of a muscle, ligament or tendon.
• It may be due to abnormal motion in a
joint or ligament. e Joint pain may be
caused by inflammation with resulting
swelling and distension.
• Compression of neural structures , as in
cervical spondylosis with encroachment on
cervical roots, may bring on pain

• Relief of pain caused by any of the above
factors requires the determination of
motion to be avoided.
• Changing the axis of weight bearing,
especially in the lower limb may also
diminish pain. Eversion or inversion of the
ankle can be corrected by wedging the
shoes to guide joint loading.

• In acute musculoskeletal conditions or
where overuse, fatigue or stretch produces
pain; pain may be relieved by
immobilization. Thus , resting splints are
commonly used for the wrist in RA., or a
supporting sling for the shoulder is used in
a patient with painful stretch of the
glenohumeral joint following hemiplegia.

2-Immobilization and Protection of
weak or painful musculoskeletal
segments
• The commonest use for an orthoses is to
immobilize a body segment. Its most obvious
application is in fracture bracing where
prevention of stress and immobilization during
fracture healing is required.
• Protection from arthritic deformity by minimizing
joint damage and pain from repeated trauma
and painful synovitis in RA.

• Temporary subsidence of symptoms
should not be an indication for discarding
the orthoses since its protective function in
an arthritic or hemophilic joint is
prophylactic.
• The patient must understands that
orthoses are for protective function not just
to relieve pain.

3-Reduction of axial load
• Reduction of the weight borne along the long axis of the
limb or the trunk is an important indication for orthoses.
• Ischial weight bearing brace used in Leg - Perthe's
disease unload the lower limb so it is useful for relieve of
pain in the knee or hip and also serves to protect the hip
from forces leading to femoral head deformity.
• Milwaukee brace is a typical example of an orthoses
responsible to reduce axial loading. This orthoses
attempt to prevent axial gravitational forces from
increasing the scoliotic deformity.

4-Prevention & Correction of
Deformities
• Prevention of deformity has its most
common application in orthotics for
children.
• In the growing child, deformity result from
lack of properly balanced muscle forces
around the joint. Unfortunately, once the
skeletal deformity is fixed, rarely will an
orthoses correct it.

• Child wearing an orthoses requires
constant supervision & instruction to the
family. They can be assured that the use
of the orthoses is usually necessary only
during the growth period.
• Muscle transplants and joint stabilization
at the conclusion of growth may allow the
brace to be discarded.

• Dynamic orthoses that apply forces with elastic
bands or springs are commonly used to prevent
or correct deformity in both children and adults.
As they stimulate muscle activity and motion,
they are more effective than passive devices in
paralytic conditions.
• Passive or resting orthoses must frequently be
removed to put the joint in optimal range of
motion.

• Once a deformity or a contracture has
developed, tissue extensibility and normal
gliding planes have been lost, force will be
required to extend contracted fibers. The
longer the condition has existed, the less
the chances for recovery of normal
physiological function. Therefore, orthoses
for correction should be prescribed early.

• Any stretching force may lead to further
tissue tears with reactive scarring and so,
forces must be kept within levels of tissue
tolerance. Because if the stretching force
induces pain, the patient will actively
contract the muscles to fight the force
imposed by the brace. Stretching splints
are perhaps most effective at night, when
the patient is relaxed.

• A brace to correct a deformity should be
constructed to apply an optimal degree of
pressure for a long period. It must be
noted that the most effective way to
reduce any deformity or contracture is to
have a normal physiological force ( an
active muscle contraction ) counteracting
the deformity.

 The most common conditions that may
produce deformities or contracture without
suitable orthotic protection are :
1. Progressive fibrous tissue diseases,
such as Dupuytren's contracture.

2. Lesions leading to reactive scarring
such as burns or local trauma.
3. Acute arthritis especially of the
shoulders, elbows & knees leading to pain
- induced inhibition of muscular action.
4. Disrupted blood supply to a muscle or
limb such as Volkman's ischemic
contracture

 Improvement of Function
a) Function is improved by all orthoses by
diminishing pain, relieving of weight
bearing and preventing deformity.
b) In many orthoses the primary purpose is
to improve function. Such types include all
those devices that assist in ambulation,
feeding, dressing and other activities of
daily living.

c) An orthoses used to improve function may do so
by stabilizing unstable limb segments or
assisting desired weak motions.
d) Many orthoses can apply active or passive
forces such as springs, elastic bands or active
motions powered by electricity.
e) All apparatus such as wheelchairs, respirators,
driving aids, environmental control apparatus
etc. may be considered as functional orthoses.

Principles of Orthotic
Applications
 Adequate surface area for comfortable pressure
distribution with accurate contouring is one of
the basic principles of design applicable to all
orthoses
 The desired function of the brace will determine
the amount of surface needed for comfort
 Where accurate contouring is difficult, it is
desirable to work from cast models.

 Comfort in an orthoses is also determined by
joint positioning. So joint design and placement
in a brace should be as close to the anatomical
features of the encircled joint as possible.
 The part to be fitted must be examined closely.
Tender areas of skin over muscle or bone should
be marked. Painful nodules, skin erosions & -
bony prominence must also be noted and
avoided since pressure over them will be painful.

 The course of nerves & blood vessels
should be outlined to avoid local
compression
 It is important in all types of bracing that
the wearer be able to don and doff his own
appliance whenever possible. The brace
should conserve time and energy of the
patient, thereby encouraging activity, not
increasing his energy consumption.

 Closing devices should be simple, the
Velcro used now is much easier than
buckles and straps and is much less
damaging to overlying clothing.

 For maintenance, orthoses should be as
simple and durable as possible. Patients
should be taught simple maintenance of
their braces, such as cleaning the leather
and oiling the joints if necessary. Most
braces will be immersed in water
periodically and so should be constructed
to withstand it.

Useful advises for the maintenance
of orthoses :
1 . Open all locks every week and with a hairpin
or fine wire, remove the lint which collect in the
joints.
2 . Place a drop of machine oil in each joint
every week.
3. Keep leather parts in good condition. Have
tears, repair at once. Perspiration stains of
leather cannot be completely removed, but
washing the leather in lukewarm water with a
good soap will help to preserve it.

4. Keep the heels and soles of the shoes
in good condition, so that no part of the
brace touches the floor while walking.
5. When the brace has been removed, put
it carefully against the wall or lay it on the
floor or table in good alignment. Handle
braces with care and avoid injuring them.

6. Examine the skin every night for
pressure marks, no metal should rub
against any part of the body.
7. Before applying, inspect braces for:
(a) Parts wearing out.
(b) Loose or missing screws or bolts.
(c) The condition of Velcro, straps or
buckles.

Functions of vertebral column
1. Protection of spinal cord.
2. Support of the trunk.
3. Transmission of the weight of head, upper
limbs & trunk to the pelvis & lower limbs

Movements of the vertebral column
1. Cervical spines
2. Thoracic spines
3. Lumbar spines

Primary objectives for the application of an
orthosis
A - Controlling the position of the spine by the use
of external forces.
B - Applying corrective forces to abnormal
curvatures.
C - Aiding spinal stability when soft tissues cannot
adequately perform theirstabilizer role.
D - Restricting spinal segment movement after
acute trauma or surgery toprotect against further
injury.

Negative effects of Spinal Qrthoses
• Axial muscle atrophy secondary to reduced
muscle activity.
• Promotes contracture of the immobilized
part.
• Psychological dependency.
• Increasing physical dependence.

Functions of Spinal Orthoses
• Relieve pain.
• Support weakened or paralyzed muscles
& unstable joints.
• Immobilize vertebral column in the best
functional position while healing occurs.
• To prevent occurrence of deformity.
• To correct an existing deformity.

Biomechanical results of spinal
orthosis depend on :
 The points of application.
 The direction and magnitude of the force
applied by the device.
 The tightness with which the device is
worn.
 The amount of force the patient exerts
against it.

In order to judge the effectiveness of an
orthosis on a particular patient, a clinician
must take radiographs in different
positions while the patient is wearing the
orthosis.

 In spite of apparent mechanical
deficiencies of spinal supports many
patients obtain symptomatic relief from
their use which may be due to :
1 Psychological effect.
2. Abdominal compression.
3. Support of pendulous abdomen.

4. Associated decreases in lumbar lordosis.
5. Change in amount of movement of the
spine.
6. Decrease activity of various associated
muscle groups.
7. Local support of S.I. joints & ilio-lumbar
ligaments.
8. From a combination of all these factors.

Indications
 To limit the movements of the neck when such
movements aggravate the symptoms.
 For limitation of muscle spasm which occurs due
to irritation of the compressed nerve.
 After trauma which may lead to heamatoma of
the muscles of the neck and spasm.
 After fracture and fracture dislocation of the
vertebrae.
 After anterior and posterior fusion of the
vertebrae.

Movements of cervical vertebrae
 Occiput - C1 articulation is responsible for
flexion & extension, minor degrees of lateral
bending and very little axial rotation.
 C1 - C2 ( atlanto -axial ) joint , its primary motion
is rotation and smaller degree of flexion &
extension. The rotation at this joint accounts for
nearly 50 % of the rotation of the entire cervical
spine in the adult.
 C2 - C3 and C3 - C4 are responsible for lateral
bending and axial rotation.
 C5 - C6 and C6 - C7 are responsible for flexion
and extension.

Types of Cervical Orthoses
1. Soft and Hard collars.
2. Philadelphia orthosis.
3. SOMI ( sternal - occipital - mandibular -
immobilizer ) orthosis
4. Poster orthosis (two or four) .
5. Yale - type cervico - thoracic orthosis.
6. Thermoplastic Minerva body jacket (TMBJ).
7. Halo jacket or vest.

Soft Cervical Collar
 Non - height
adjustable.
 Made of foam rubber
covered by stockinet
 Low in cost and easy
to fabricate.
 Has a Velcro closure
located either
posteriorly or
anteriorly.

 Foam is contoured to accommodate the
chin, one inch thick, the length & width
change with collar size
 The closure is the stiffest part of the collar,
thus extension is most inhibited with the
closure posteriorly & flexion is most
inhibited with the closure anteriorly.
 Well tolerated by most patients.

 Does not restrict cervical motion in any plane.
 Does not provide support.
 Provides warmth & psychological comfort.
 Serves only as a reminder to hold the neck
relatively still.
 Soft collar is indicated for patient with soft tissue
injuries such as muscle strain from whiplash.
 Soft collar is contraindicated for any injury or
deformity requiring restriction of vertebral
motion.

Hard Cervical Collar
 Made of rigid polyethylene.
 May be height or non - height adjustable.
 Can have optional occipital and mandibular
support
 These supports gives more restriction in flexion
and extension but not truly effective.
 Does not limit lateral bending or rotation.
 Does not contact on the thorax.
 Can press on the clavicles, creating areas of
high pressure with subsequent discomfort.

Philadelphia (collar) orthosis
 Made of plastazote reinforced with anterior and
posterior plastic struts.
 The plastazote is contoured to be in nearly total
contact with the skin.
 The front and rear halves fasten with Velcro
closures.
 Has a molded mandibular and occipital support.
 The anterior and posterior caudal aspect of the
brace extends onto the upper thorax.

 Restrict particularly
flexion & extension
due to better fit at the
occiput and the chin
as well as the
improved contact on
the upper thorax.

 Relatively ineffective in controlling rotation
& lateral bending.
 Used for strains, sprains and stable bony
fractures and ligamentous injuries of
cervical spine.

 Also used to wean patients off of more
rigid stabilization.
 Contraindicated in unstable ligamentous
and bony injuries. Also contraindicated
where total contact cannot be tolerated on
the chin, shoulders, occiput or sternum.

Poster collars
 There are 2 Poster & 4
Poster collar.
 The Guilford brace, is a
two - poster brace with a
front and back strut
connecting the anterior
and posterior thoracic
plates to the chin and
occipital piece. The
strapping runs over the
shoulder as well as under
the axilla.
4 poster cervical
orthosis

 The four - poster brace represents the first true
cervical thoracic orthosis.
1. It has a molded mandibular and occipital
support with adjustable struts attaching to
anterior and posterior padded thoracic plates.
2. The mandibular and occipital supports can be
held together with straps running below the ears.
3. The anterior and posterior thoracic pads are
connected by leather shoulder straps.
4. There are no straps under the axilla.

 They are used for mid - to low - cervical
stable fractures.
 Contraindicated for unstable fractures or
unstable ligamentous injuries.
 Contraindicated for patients unable to
tolerate pressure on the chin, occiput,
sternum or back.

Yale orthosis
 A true cervical thoracic brace.
 Considered as a modified Philadelphia
collar with molded plastazote reinforced
with plastic struts.
 It extends down onto the anterior and
posterior thorax, with strapping beneath
the axilla.

 The occipital piece
extends higher on the
skull than does the
original Philadelphia
orthosis. The
increased contact on
the body surface at
the occiput and onto
the thorax improves
the stability that this
brace offers.
Yale orthosis

SOMI orthosis
 SOMI (Sternal Occipital
Mandibular Immobilization
) is also a cervicothoracic
orthosis.
 It has a rigid anterior
plastic chest piece and
shoulders straps.
 The occipital piece is
attached with two posters,
which run anteriorly.
SOMI orthosis

 The mandibular piece has a single poster, which
also attaches anteriorly.
 These posters are made of rigid aluminum.
 The strapping crosses under the arms to the
base of the chest piece.
 This brace can be applied without moving the
patient from the supine position, an advantage in
the spinal cord - injured patient.

 It is indicated in post - surgical fusion and
stable cervical fractures and ligamentous
injuries.
 Because the SMOI is designed to allow
amount of freedom in cervical extension,
injuries that require extension control
should not be fit with this orthosis.
 This orthosis is unsuitable for unstable
fractures or ligamentous injuries.

Halo brace
 Halo brace is the most
frequently used
 method of treating
cervical fractures or
dislocations.
 There are basically two
types of halo orthotic
devices currently used to
control neck motion. They
are the halo cast and
halo vest.
Halo brace

 The halo component is the same on each
type and consists of a rigid metal or
graphite ring attached to the skull with four
fixation pins. Two anteriorly , usually in the
frontal region and two posteriorly in the
parieto - occipital area.

 The anterior pins are placed 1 cm above
the orbital rim, this avoids the
supratrochlear and the supraorbital
nerves, the medial frontal sinus , and the
temporalis muscle.
 Posterior pin placement is much less
critical because of the lack of
neuromuscular structures and the
uniformity and thickness of the skull.

 The posterior pin should be placed
diagonally across from the anterior pin and
should be tightened with its diagonal
partner to maximize uniformity of pin
tightening and prevent halo migration.
 The halo pins should be inserted
perpendicularly to the horizontal diameter
of the skull to prevent migration.

 The ring must not contact the head or ears and
should be at least 1 cm away from the skull at
any site. The ring is typically positioned 1 cm
superior to the eyebrow afthe top of the ear.
 The ring is bolted to four posters which run down
onto either a polyethylene vest prefabricated like
an " X" or a plaster cast, both of them extend to
about the umbilicus.

 Straps extend over each shoulder and
under each arm to connect the chest and
back portions.
 The HALO is indicated for unstable
fractures of all levels of the cervical spine.
 The HALO is relatively contraindicated in
cranial fractures

Thermoplastic Minerva body jacket
(TMBJ)
 The original Minerva
molded - type orthosis
contacts the head &
the thorax but not
better than the
traditional
Philadelphia or four
poster orthoses.
Original Minerva

 The newer design of
the Minerva body
jacket (TMBJ) runs
down to the thorax to
a level similar to that
of the halo vest. It
provides significant
contact on the head
with its circumferential
forehead adaptation.
TMBJ

 It is non-invasive, an advantage over the
Halo brace whose pins present the risk of
infection and slippage. Both Minerva and
Halo vest are the treatment of choice in
the ambulatory management of the
unstable cervical spine.

 The Minerva vest provides necessary
stabilization and was lighter and more
comfortable. This allows mobilization of
the patient for rehabilitation with
satisfactory stabilization of the cervical
spine.
 It appears that TMBJ can be an alternative
to the Halo in selected patients.

The effects of different Cervical Orthoses on
normal cervical motion from occiput to first thoracic
vertebra
Means
of Normal
Motion
(%)
Flexion /
Extension
Lateral Bending Rotation
Normal 100.0 100.0 100.0
Soft collar 74.2 92.3 82.6
Philadelphia collar 28.9 66.4 43.7
Four-poster brace 20.6 45.9 27.1
Yale cervicothoracic brace 12.8 50.5 18.2
SOMt brace 27.7 65.6 33.6
Halo device 4.0 4.0 1.0
Minerva body jacket 14.0 15.5 0

Thoracolumbar orthotics
 Thoracolumbar orthotics (TLOs) are used
mainly to treat fractures from T10-L2 since
their mobility is not restricted by the ribs,
unlike fractures from T2-T9. Immobilization
from T10-L2 helps prevent further
collapse.

The cruciform anterior spinal
hyperextension (CASH) brace :
 Shows anterior sternal and pubic pads to
produce force opposed by the posterior
pad and strap around the thoracolumbar
region. Sternal and pelvic pads attach to
the anterior metal cross-shaped bar, which
can be bent to reduce excess pressure on
the chest and pelvis.

 The brace is easy to
don and doff, but it is
difficult to adjust.
Compared to the
Jewett brace, it
provides greater
breast and axillary
pressure relief.

 Two round upper chest pads can be used
instead of the sternal pad to decrease
discomfort around the breast area.
Average cost of a CASH brace is
approximately $460.

 Indications for the CASH brace include the
following:
 -Flexion immobilization to treat thoracic
and lumbar vertebral body fractures.
 -Reduction of kyphosis in patients with
osteoporosis


 Motion restrictions provided by the CASH
brace include the following:
-Limits flexion and extension from T6-L1
-Ineffective in limiting lateral bending and
rotation of the upper lumbar spine

 Contraindications to use of the CASH
-Three-column spine fractures involving
anterior, middle, and posterior spinal
structures
-Compression fractures due to osteoporosis

 The Jewett hyperextension
brace:
-Uses a 3-point pressure system
with 1 posterior and 2 anterior
pads. The anterior pads place
pressure over the sternum and
pubic symphysis.

-The posterior pad places opposing
pressure in the mid-thoracic region. The
posterior pad keeps the spine in an
extended position, and it has a lightweight
design that is more comfortable than the
CASH brace.

-Pelvic and sternal pads can be adjusted
from the lateral axillary bar where they
attach. The pads can cause discomfort
from pressure applied to small surface
area.

-No abdominal support is provided with this
device. When the patient is seated, the
sternal pad should be half an inch inferior
to the sternal notch, and the pubic pad
should be half an inch superior to the
pubic symphysis. The Jewett brace is not
a custom-molded brace and costs
approximately $460.

 Indications for use of the Jewett brace
include the following:
-Symptomatic relief of compression fractures
not due to osteoporosis
-Immobilization after surgical stabilization of
thoracolumbar fractures

 Motion restrictions provided by the Jewett
-Limits flexion and extension between T6-L1
-Ineffective in limiting lateral bending and
rotation of the upper lumbar spine

 Contraindications to use the Jewett brace
-Three column spine fractures involving anterior,
middle, and posterior spinal structures
-Compression fractures above T6 since segmental
motion increases above the sternal pad
-Compression fractures due to osteoporosis
* One important consideration in use of the Jewett
brace is that it is more effective than the CASH
brace.

 The Korsain brace:
Is a modification of the Jewett brace with
added abdominal support for increased
rigidity. The cost of the Korsain brace is
similar to that of the Jewett brace.

 Indications for the Korsain brace include the
following:
-Symptomatic relief of compression fractures not
due to osteoporosis
-Immobilization after surgical stabilization of
thoracolumbar fractures
-Flexion immobilization to treat thoracic and
lumbar vertebral body fractures
*Motion restrictions and contraindications of the
Korsain brace are similar to the Jewett brace.

 The Knight-Taylor brace:
-Has a corset type front with
lateral and posterior uprights
and shoulder straps to help
reduce lateral bending,
flexion, and extension.
Shoulder straps may cause
discomfort in some patients.

-The brace can be prefabricated and made
with polyvinyl chloride or aluminum. The
posterior portion of the brace has added
cross supports below the inferior angle of
the scapula and a pelvic band fitted at the
sacrococcygeal junction.

 The anterior corset is made of canvas and
provides intracavitary pressure. The
anterior corset is laced to the lateral
uprights. Average cost of the Knight-Taylor
brace is approximately $540.

 The brace is indicated to:
Provide flexion immobilization to treat thoracic and
lumbar vertebral body fractures.
 Motion restrictions of the Knight-Taylor brace
-Poor rotation control
-Limits flexion, extension, and lateral bending

Thoracolumbosacral orthosis
 Custom-molded
plastic body jacket, or
thoracolumbosacral
orthosis (TLSO), is
fabricated from
polypropylene or
plastic and offers best
control in all planes of
motion and increases
intracavitary pressure.

 This orthosis has a lightweight design and
is easy to don and doff. The material is
easy to clean and comfortable to wear.
This brace sometimes is referred to as the
clamshell.

 The TLSO provides efficient force
transmission as pressure is distributed
over wide surface area, which is ideal for
use in patients with neurologic injuries.

 The brace may have a tendency to ride up
on the patient in a supine position. Plastic
retains heat, so an undershirt helps to
absorb perspiration and protect the skin.
Frequent checks to ensure proper fit help
prevent pressure ulcers. Velcro straps are
used to tighten the brace. Average cost of
a TLSO with Polyform material is $1250 to
$1700.

 Indications for the TLSO include the
following:
-Immobilization for compression fractures
from osteoporosis
-Bracing for idiopathic scoliosis
-Immobilization for unstable spinal disorders
for T3 to L3

 Motion restrictions for the TLSO include
the following:
-Limits sidebending
-Limits flexion and extension
-Limits rotation to some extent

 Clinical information on the custom-molded
TLSO suggests that it is more effective in
preventing idiopathic scoliosis curve
progression than the Milwaukee and
Charleston braces.

 The mean curve progression with TLSO is
less than 2° while the Charleston and
Milwaukee braces have a curve
progression greater than 6°. Fewer than
18% of patients treated with TLSO brace
required surgery for scoliosis compared to
23% for patients treated with a Milwaukee
brace.

Lumbosacral orthotics
 The chairback brace:
-Is a rigid short lumbosacral
orthotic (LSO) with 2 posterior
uprights with thoracic and
pelvic bands.

-The abdominal apron has straps in front for
adjustment to increase intracavitary
pressure. The thoracic band is located 1
inch below the inferior angle of scapula.

-The thoracic band extends laterally to the
mid-axillary line, and the pelvic band
extends laterally to the mid-trochanteric
line.
-Place the pelvic band as low as possible
without interfering with sitting comfort.
Position the posterior uprights over the
paraspinal muscles.

 Uprights can be made from metal or
plastic. The brace uses a 3-point pressure
system and can be custom molded to
improve the fit for each individual patient.
The chairback brace costs approximately
$440.

 Indications for use of the chairback brace
-Unloading of the intervertebral discs and
transmit pressure to soft tissue areas
-Relief for low back pain (LBP)
-Immobilization after lumbar laminectomy
-Kinesthetic reminder to patient following
surgery

 Motion restrictions of the chairback brace
-Limits flexion and extension at the L1-L4
level
-Limits rotation minimally
-Limits lateral bending by 45% in the
thoracolumbar spine

 The chairback Ortho-Mold
brace:
-Is similar to the chairback
brace, but it has a rigid
plastic back piece custom
molded to the patient. The
plastic back can be inserted
into the canvas and elastic
corset. The chairback
Ortho-Mold brace costs
approximately $500-600.

 Indications for use of the chairback Ortho-
Mold brace and its motion restrictions are
the same as the chairback brace noted
above.

 The Williams brace:
- Is a short LSO with an
anterior elastic apron
to allow for forward
flexion. Lateral
uprights attach to the
thoracic band, and
oblique bars are used
to connect the pelvic
band to the lateral
uprights.

- The abdominal apron is laced to the lateral
uprights. The brace limits extension and
lateral trunk movement but allows forward
flexion. The Williams brace costs
approximately $500.

 The brace is indicated to:
- Provide motion restriction during extension
to treat spondylolysis and
spondylolisthesis. The device is
contraindicated in spinal compression
fractures.

 Motion restrictions of the Williams brace
-Limits extension
-Limits side bending at terminal ends only

 The MacAusland brace:
-Is an LSO that limits only flexion and
extension. This brace has 2 posterior
uprights but no lateral uprights. The 3
anteriorly directed straps connect with the
abdominal apron to provide increased
support. The MacAusland brace costs
approximately $510.

-Indications for use of the MacAusland brace
are similar to the chairback brace.
- Motion restrictions include limitation of
flexion and extension in the L1 to L4 level.

 The Standard LSO
corset:
- Has metal bars within
the cloth material
posteriorly that can be
removed and
adjusted to fit the
patient. The anterior
abdominal apron has
pull-up laces from the
back to tighten.

- The abdominal apron can come with
Velcro closure for easy donning and
doffing. The Standard LSO corset has a
lightweight design and is comfortable to
wear.

-The corset increases intracavitary pressure.
Anteriorly, the brace covers the area
between the xiphoid process and pubic
symphysis. Posteriorly, the brace covers
the area between the lower scapula and
gluteal fold. Average cost for the corset is
approximately $150.

 Indications for the Standard LSO corset
-Treatment of LBP
-Immobilization after lumbar laminectomy
*Motion restrictions of the Standard LSO
corset include limitation of flexion and
extension.

 The rigid LSO:
- Is a custom-made
orthosis molded over
the iliac crest for
improved fit. Plastic
anterior and posterior
shells overlap for a
tight fit. Velcro closure
in the front is
designed for easy
donning and doffing.

- Multiple holes can be made for aeration to
help decrease moisture and limit skin
maceration. The rigid LSO can be trimmed
easily to make adjustments for patient
comfort and may be used in the shower if
needed. A rigid LSO costs approximately
$500-700.

 Indications for use of the rigid LSO brace
-Post-surgical lumbar immobilization
-Treatment of lumbar compression fractures

 Motion restrictions provided by the rigid
LSO brace include the following:
-Limits some rotation and side bending

 Rigid LSO with hip spica:
- Uses a thigh piece on the symptomatic
side and extends to 5 cm above the
patella. The hip is held in 20° of flexion to
allow sitting and walking. Some patients
require a cane for ambulation after
application. Average cost of a rigid LSO
with hip spica is about $1100.

 Indications for the rigid LSO with hip spica
use include the following:
-Immobilization to treat lumbar instability
from L3-S1
-Immobilization after lumbosacral fusion with
anchoring to the sacrum

 Motion restrictions of the rigid LSO with
hip spica include the following:
-Limits some rotation and side bending
* New brace designs for LSO have strapping
systems designed to pull the brace inward
and up to improve hydrostatic affect to
relieve pressure on the lumbar spine. The
better fit helps limit migration.

* Some low-profile designs take pressure off
the hip and rib area, which, in turn,
improves patient compliance. Low-profile
braces allow easier fitting under clothes.
These braces can treat areas from L3-S1.
* Some spinal braces come with an
interchangeable back with an open center
or flat back design for postoperative
patients.

*The same brace can be interchanged with
a back that has an indentation to fit the
lordotic curvature of the lumbar spine for
pain management purposes.

*Braces with interchangeable parts allow a
LSO to be converted into a TLSO with a
large back support and an attachment for
a sternal extension to prevent unwanted
flexion. The sternal extension has straps
that attach to the LSO>

Bracing for scoliosis
 The main goal of a
brace in scoliosis is to
prevent further
deformity and prevent
or delay need for
surgery. If surgery is
needed, delaying the
procedure as long as
possible helps
optimize spinal height
and avoid stunting of
truncal growth.

 Assessing the degree of skeletal maturity
in a child with scoliosis is important
because with more advanced skeletal
maturity, you expect less further skeletal
growth and thus less progression of the
scoliosis. This has obvious implications
when forming a treatment plan.

 Risser classification of ossification of the
iliac epiphysis is used to evaluate skeletal
immaturity. Ossification of the iliac crest
occurs from the anterior superior iliac
spine (ASIS) to the posterior superior iliac
spine (PSIS).

 When ossification is complete, fusion of
the epiphysis occurs to the iliac crest.
Risser staging is based on using
radiographs to determine what percent of
the excursion (along the length of the iliac
epiphysis) has ossified. Risser score of 0-I
with a curve of 20-30° indicates nearly
70% chance of progression.

 Risser stages are defined
as follows:
-Stage 0 = 0% excursion
-Stage I = 25% excursion
-Stage II = 50% excursion
-Stage III = 75% excursion
-Stage IV = 100% excursion
and correlates with end of
spinal growth
-Stage V = fusion to ilium,
indicating cessation of
vertical height growth

 The clinician must take into account
several bits of clinical information about
use of braces in scoliosis including the
following:
-Patients with pre-brace curves of 20-29°
require surgery in only 3% of cases,
whereas 28% of patients with pre-brace
curves of 40-49° require surgery.

 -Patients aged younger than 13 years with
curves of 30-39° require surgery 25% of the
time, whereas only 14% of patients older than 14
years with curves 30-39° require surgery.
 -The most common time to lose control of
idiopathic curves is at puberty. Boys tend to
show less curve progression than girls, and tend
to have later onset of curve progression
between 15-18 years.

 -Younger patients show greater initial in-brace
correction. Curve correction with bracing greater
than 50% is expected to have final net
correction, whereas curve correction less than
50% is expected to have limited progression.
 -Generally, curves between T8-L2 have the best
correction. Young patients with large curves
usually fail treatment with a brace.

-Patients successfully completing treatment
for idiopathic scoliosis using a TLSO with
initial curves measuring 20-45° can
anticipate their scoliosis to remain stable
until adulthood. The correction of the
curvature can be lost over time, to its initial
magnitude. Therefore, obtaining a spinal
radiograph in the third or fourth decade of
life to check progression is reasonable.

The Milwaukee
brace:
-Is a CTLSO originally
designed by Blount and
Schmidt to help maintain
postoperative correction in
patients with scoliosis
secondary to polio. The
brace is designed to
stimulate corrective forces
from the patient.

-When the patient has been fitted properly
with a brace, the trunk muscles are in
constant use; therefore, disuse atrophy
does not occur.
-The brace has an open design with
constant force provided by the plastic
pelvic mold. The pelvic portion helps
reduce lordosis, derotates the spine, and
corrects frontal deformity.

-Uprights have localized pads to apply
transverse force, which is effective for
small curves. The main corrective force is
the thoracic pad, which attaches to the 2
posterior uprights and 1 anterior upright.
-Discomfort from the thoracic pad creates a
righting response to an upright posture.
The lumbar pads play a passive role
compared to the thoracic pads.

-The uprights are perpendicular to the pelvic
section, so any leg-length discrepancy should be
corrected to level the pelvis. The neck ring is
another corrective force and is designed to give
longitudinal traction.
-Jaw deformity is a potential complication of the
neck ring. The throat mold, instead of a
mandibular mold, allows use of distractive force
without jaw deformity.

 During the child's growth, brace length can
be adjusted. Pads also can be changed to
compensate for spinal growth. The brace
needs to be changed if pelvic size
increases. Average cost of this brace is
approximately $2100-2300.

 Indications for use of the Milwaukee brace
-Patients with Risser score of I-II and curves
greater than 20-30° that progress by 5° over 1
year need application of brace.
-Curves between 30-40° need bracing, but not
curves less than 20°.
-Curves of 20-30°, with no year-over-year
progression, require observation every 4-6
months. The Milwaukee brace is used for curves
with apex above T7.

 Duration of the Milwaukee brace use is
determined by the following criteria:
-Daily use ranges from 16-23 hours per day.
-Treatment should continue until the patient
is at Risser stage IV or V.
-If curve is greater than 30°, consider
continued use for 1-2 years after maturity
since patients with curves of this
magnitude are at risk for progression.

 Side effects of the Milwaukee brace include the
following:
-Jaw deformity
-Pain
-Skin breakdown
-Unsightly appearance
-Difficulty with mobility
-Difficulty with transfers
-Increased energy expenditure with ambulation

 Failure to correct deformity can be caused
by any of the following:
-Poor patient compliance
-Improper fit
-Curves below T7

 Keep in mind clinical information regarding
use of the Milwaukee brace, including the
following:
*Only 40% of patients with curves of 20-29°
progressed with a Milwaukee brace,
compared to 68% by natural history
without bracing.

*When comparing the Milwaukee and
Boston braces, note that curve
progression beyond 45° occurred in 31%
of patients with the Boston brace and in
62% with the Milwaukee brace.
* X-rays to evaluate scoliosis in the
Milwaukee brace are performed with the
patient in a standing position.

* Successful outcomes with brace treatment
show an in-brace curve reduction greater
than 50%.
* The Milwaukee brace and a custom-made
TLSO can be used to treat Scheuermann
kyphosis in children with pain, or pain with
kyphosis greater than 60°.

The Boston brace:
-Is a prefabricated symmetric
thoracolumbar-pelvic mold with
built-in lumbar flexion that can
be worn under clothes. Lumbar
flexion is achieved through
posterior flattening of the brace
and extending of the mold
distally to the buttock.

-Braces with superstructures have a curve
apex above T7. Curves with an apex at or
below T7 do not require superstructures to
immobilize cervical spine movement.
-This brace, unlike the Milwaukee brace,
cannot be adjusted if the patient grows in
height. Both braces need to be changed if
pelvic size increases. Average cost of the
Boston brace is approximately $2000.

 Indications for use of the Boston brace
-Curves 20-25° with 10° progression over 1
year
-Curves 25-30° with 5° progression over 1
year
-Skeletally immature patients with curves
30° or greater

 Side effects associated with use of the Boston
-Local discomfort
-Hip flexion contracture
-Trunk weakness
-Increased abdominal pressure
-Skin breakdown
-Accentuation of hypokyphosis above brace in the
thoracic spine

 Certain preventive measures can reduce
difficulties associated with use of the Boston
brace, including the following:
-Regimen of hip stretches decreases contractures
at the hip.
-Exercise to promote active correction in the brace
is suggested.
* Presence of thoracic hypokyphosis is a relative
contraindication for use of the Boston brace.

 Failure of the Boston brace to correct
deformity can occur because of several
factors, including the following:
-Curve above T7
-Improper fit
-Poor patient compliance

 Duration of Boston brace use is determined by
several factors, including the following:
-Daily use ranges from 16-23 hours per day.
-Treatment should continue until the patient is at
Risser stage IV or V.
-If the curve is greater than 30°, consider
continued use for 1-2 years after maturity since
these curves are at risk for progression.
-The Boston brace with and without superstructure
is equally effective in treating curves below T7.

 Clinical information relevant to use of the
Boston brace includes the following:
-The Boston brace is more effective than the
Charleston brace in preventing curve
progression and avoiding surgery.
-Nearly 43% of patients using the Boston
brace progressed more than 5°, compared
to 83% with the Charleston brace.

-The use of a Charleston brace is only indicated
with lumbar or small thoracolumbar curves;
avoid use in thoracic curves.
- X-rays to evaluate scoliosis in the Boston brace
are performed with the patient in a standing
position.
- Successful outcomes with brace treatment show
an in-brace curve reduction greater than 50%.
-

The Charleston
bending brace
 It is a rigid custom-made
orthosis designed to correct
scoliosis at nighttime to
improve patient compliance.
This brace holds the patient
in maximum side-bending
correction. The Charleston
bending brace costs
approximately $2000.

 Indications for use of this particular brace
- Curves 20-25° with 10° progression over 1
year
- Curves 25-30° with 5° progression over 1
year
- Skeletally immature patients with curves
30° or greater

 Clinical information regarding use of the
Charleston bending brace includes the
following:
- The Charleston brace, compared to the
Boston brace, is significantly less effective
in treating double major curves and single
thoracic curves in patients with Risser
stage 0 to 1.

- Over 50% of patients with a single thoracic curve
treated with a Charleston brace required surgery
compared to 24% with the Boston brace.
- As a result, the Charleston brace is not
recommended for use in thoracic curves.
- The Charleston brace is less effective at treating
single thoracolumbar or lumbar curves, but the
figures are not statistically significant compared
to those for the Boston brace.

- X-rays to evaluate scoliosis with the
Charleston bending brace are performed
in a supine position since the patient
wears it at night sleeping supine.
- Successful outcomes with brace treatment
show an in-brace curve reduction greater
than 50%.

Spinal orthosis

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