Spinal Orthoses
PTA 104 Orthopedic Dysfunctions Lab

Orthoses as a Spinal Intervention

Corsets and spinal orthosis can be an integral component of the physical therapy plan of care for spinal pain management. Spinal orthoses can be used during the acute (e.g., following surgery), subacute, and chronic stages of tissue healing and spinal rehabilitation.

Primary Goals of Spinal Orthoses

• decrease pain
• by limiting motion
• by providing greater abdominal support

PTs and PTAs recognize the effects of postural impairments on spinal pain. Optimal lumbar posture can be an important contributor to pain reduction, and orthoses can facilitate maintaining optimal posture.

Impairment-Based Considerations

• Nonspecific-mechanical chronic back pain
• effective pain relief is often accomplished by positioning the spine in lumbar extension.

• Instability, flexion-bias, non-weight bearing syndromes (neurocompressive disorders)
• pain relief is usually accomplished when orthosis is oriented toward lumbar flexion.
• Cervical Instability due to fracture, degeneration or soft tissue injury
• pain relief is usually accomplished through immobilize specific levels and specific planes of movement.

A wide variety of orthotic designs, ranging from lumbosacral corsets to rigid thermoplastic thoracolumbosacral orthoses (TLSOs), meet this goal. For back pain with discogenic-mechanical etiology, useful orthoses include lumbosacral or dorsolumbar corsets, chairback or Knight LSOs, various commercially produced prefabricated LSOs, or custom-molded LSOs. For individuals with pain from stenosis or spondylolisthesis, the most commonly prescribed orthoses include lumbosacral corsets chairback or Knight LSOs, prefabricated LSOs, Raney or Williams Flexion LSOs, or custom-molded LSOs.

Rigid Thermoplastic or Metal Orthoses, or Both

Soft Garments and Supports

Practical Applications

Active Learning Exercise

Describe in your own words how this featured brace depicts a 3 -point pressure system. Bring your response to lab for peer review discussion

Active Learning Exercise

Careful observation of orthoses components can often indicate which structures are receiving the greatest amount of stabilization. For example, by looking at this image, you should be able to name it:

Take a look at this CTO and write down the points of contact for the rigid structures: Note the 'U' Shaped rod which connects the occiput to the sternum. If tension was released in the 'U' rod, what limited motion(s) would become available? Based on the points of contact, do you suspect an upper cervical or lower cervical instability? What areas will you check for skin breakdown? What would be your primary indicator of signs/symptoms of misfit?

Halo Jackets

A halo vest/jacket is the only orthosis which completely limits cervical motion in all three planes. It can be used conservatively or post-operatively to insure adequate healing time for cervical stabilization. The head is stabilized by pressure pins inserted 1/8" into the skull above the lateral 1/3rd of the eyebrow and just posterior to the ear. PT/PTAs are involved in inspecting pin sites for signs and symptoms of infection and reporting findings to appropriate medical personnel. Pins may also loosen over time, shifting out of the skull or into dural tissue. NEVER PULL ON THE HALO JACKET OR USE IT AS A POINT OF MANUAL CONTACT DURING FUNCTIONAL MOBILITY TRAINING. The anterior component of the jacket can be removed in supine for hygiene and for emergency medical procedures.

Scoliosis

Custom molded or 4 point rigid orthoses may be used to prevent progression of scoliosis. Effective wear time ranges from 18-23 hours/day. In some cases where compliance is an issue, effects can be acheived through a night time wear schedule. Your text provides examples of orthoses used in scoliosis management.

More Clinical Considerations

• Collars 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 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.
• 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
• 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.
• 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.
• Coordinate closely with the PT and the CPO 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.
• 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.
• Sexual activity is often signficantly inhibited in patients who need spinal bracing. PTs and PTAs are often consulted by patients in 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.