More Clinical Considerations

For your exam, you will be asked to make clinical-decisions based on case simulations with a patient who is prescribed a spine orthoses as part of their rehabilitation.

Coordinate care with the interprofessional team. Work closely with the PT and the CPO (Certified Prosthetist Orthotist) for the latest products which are supported by research. There are many off-the-shelf brands and claims for support. Be sure that you use resources in your community and facility to help coordinate care when it comes to appropriate bracing and bracing modification.

Check fit and reinforce patient education on brace purpose and proper fit. Collars and orthoses are hot, awkward, and limit peripheral vision. Patients, family members and health care personnel are often compelled to loosen collars to increase comfort. If a collar or orthoses is loosened more than when the patient was originally fitted for the device, the effect of the collar is eliminated. The spine will move. PTAs are an integral member of the health care team who educate the patient on importance of proper, snug fit of spinal orthoses when upright. Tissue shifts with weight bearing. Retightening of the orthosis is necessary before the person wearing the orthosis changes from a supine position into sitting or standing postures.

Observe and inspect for signs and symptoms of skin or pressure injury. Pressure from weight bearing or from lying on the orthosis can lead to skin breakdown. Check for capillary refill or excessive blanching when the orthosis is removed. Stage 1 pressure areas should be reported to medical personnel and the PT in order to schedule brace and positioning modifications as needed. Check to be sure the patient is wearing an approved stockinette or undershirt when using a CTO or CTLO. Stockinettes absorb moisture and provide a modest friction barrier between skin and rigid components/straps

Apply principles of therapeutic positioning to optimize movement and prevent injury. Optimally, only a single pillow placed under the upper back (scapula), neck, and head is used for sleeping. When several pillows are placed under the person's head and neck, a large flexion moment is created, which, in turn, creates areas of high-pressure contact with the skin, increasing discomfort and the risk of skin breakdown.

Acknowledge the contextual factors that interfere with adherence and take time to educate. The aesthetics of bracing can often lead to non-compliance with wear time. Patients can perceive donning a brace to get to the restroom a nuisance-level task. Adolescents and teens are more likely to avoid wearing spinal orthoses. Frequent patient education on the risks of increasing instability and further injury/disability is often necessary in order to solidify understanding reasons for non-use.

Allow for questions about personal matters, such as hygiene and sexual activity. Sexual activity is often signficantly inhibited in patients who need spinal bracing. Patients may consult PTs and PTAs about how to assume sexual positions while minimizing risks for further injury. Rolled towels under the lumbar spine, kneeling positions and supported sidelying positions are several options to minimize spinal motion and sustained spinal position. Sex and Back Pain by Lauren Hebert, PT, OCS is an excellent resource for patients and PT/PTAs, complete with illustrations and positioning recommendations. There is an ebook version available for a very low cost.