Spinal Orthosis Lecture Notes PDF

SPINAL ORTHOTICS Dr. Nesreen Fawzy Mahmoud Ali They limit neck motion by up to 10% in all directions.  REINFORCED CERVICAL COLLAR These collars typically have: o A hard shell on the front and back o Padding inside for comfort o Velcro closures for adjustabilit...

SPINAL ORTHOTICS Dr. Nesreen Fawzy Mahmoud Ali They limit neck motion by up to 10% in all directions.  REINFORCED CERVICAL COLLAR These collars typically have: o A hard shell on the front and back o Padding inside for comfort o Velcro closures for adjustability Most collars have openings in the front to allow for easier breathing and use with medical equipment. The chin area and the clavicle are a common place for skin breakdown. Height can be adjusted  REINFORCED CERVICAL COLLAR Choosing the right collar is important to prevent further injury after spine trauma (3% to 25% of injuries happen later). Proper fit is crucial - a bad fit is like not wearing a collar at all. Bad-fitting collars allow more movement, especially in twisting and bending.  REINFORCED CERVICAL COLLAR Different collars restrict neck motion differently. Studies show:  NecLoc collar is best for limiting all types of neck movement, followed by the Miami J collar. Some collars put too much pressure on the skin, which can be a problem (Stifneck collar is the worst in this regard). Miami J is a good option for pressure.  Miami J collar is better than Philadelphia, Stifneck and Aspen collars.  REINFORCED CERVICAL COLLAR WITH THORACIC EXTENSION Many semi-rigid cervical collars can be converted to a CTO (cervicothoracic orthosis) with add-on thoracic extension kits. These kits are detachable, allowing for: o Increased support when needed (more stabilization/immobilization). o Removal of extra support as healing progresses (less restriction). This adjustability makes them ideal for post-surgical use.  SOMI This orthosis was designed to be applied to a supine patient who is not permitted upright posture without orthotic support. Because it does not have a posterior thoracic plate, it may be more comfortable for patients who must remain supine. It is able to restrict movement in all three planes, but it is most effective in limiting flexion at C1 through C3 and is least effective in controlling extension. Effective control is dependent on proper fitting and donning, which is difficult in patients with high body mass indices (BMIs). THE TWO-POSTER BRACE (GUILFORD BRACE) The motion restrictions afforded by the Guilford brace include limitation of flexion and extension from C3-T2.  6- MINERVA ORTHOSIS (PINLESS HALO ORTHOSIS) Originally a custom cast, now prefabricated for children and adults. Considered a good alternative to a halo device. Design: o Molded shell for the back of the neck and head. o Headband to stabilize the head. o Chin support piece. o Connects to a torso brace or chest plates.  ORTHOTIC DEVICES CONTROL VARIOUS CERVICAL REGIONS All orthotics tend to control flexion better than extension. 1. The SOMI brace is best at controlling flexion from C1-C5. 2. The SOMI is less effective in controlling extension compared to other orthotics.  ORTHOTIC DEVICES CONTROL VARIOUS CERVICAL REGIONS 1. The halo is the most effective in controlling flexion and extension at C1-C3, followed by the four-poster brace. 2. The halo is the best at controlling rotation and lateral bending from C1-C3. 3. The four-poster brace is slightly better at controlling lateral bending.  TRUNK ORTHOSES Trunk orthoses, composed of soft or rigid materials, are referred to by the region of the spine to which they are applied. 1. Thus, soft spinal orthoses include: Thoracolumbosacral corsets Lumbosacral corsets or belts Sacroiliac belts. 2. Rigid trunk orthoses Thoracic orthoses are called TLSOs lumbar orthoses are called LSOs. 3. trunk orthoses for scoliosis. (Although most scoliosis orthoses are rigid, a few are constructed from soft materials).  SOFT TRUNK ORTHOSES: Corsets and Belts Corsets and belts do not have any rigid horizontal components, but they may have vertical stays to prevent the fabric from rolling or may have metal or molded plastic inserts to provide additional support in specific areas. LUMBOSACRAL CORSETS Traditionally, lumbosacral corsets extend from the xiphoid to the pubic symphysis anteriorly, and posteriorly they extend from just inferior to the scapulae to as low on the buttocks as possible without interfering with sitting. The material over the abdomen, often called an apron, usually provides an opening and closure method for donning and doffing the appliance.  LUMBOSACRAL CORSETS Some have proposed that corsets improve back pain symptoms by compressing the abdominal contents, altering the contraction of trunk and abdominal muscles, increasing intra-abdominal pressure (IAP), thus unloading, to some degree, the lumbar intervertebral discs. (Although some corsets can increase IAP, it does not appear to produce the putative unloading effect.) Other researchers have demonstrated that lumbosacral belts or corsets can contribute to passive lumbar stiffness or stability and slightly reduce erector spinae activity but have no effect on abdominal muscle activity or lumbar joint stability.  LUMBOSACRAL CORSETS Additionally, pelvic motion in the sagittal and transverse planes is only minimally affected by wearing a corset, although moderate frontal plane movement restriction can occur. Others suggest that in addition to minimal benefits, continued use of a corset may actually have a negative effect on its wearer by reducing back and abdominal muscle strength. However, in a study in which normal subjects wore lumbosacral corsets for 21 days, no loss of muscle strength was identified. THORACOLUMBOSACRAL (TLS) It extends further into the thoracic region, between or over the scapulae, and typically have axillary straps that wrap around the axillae (from posterior to anterior) to limit thoracic flexion. Although some TLS corsets only have posterior contact with the ribs, others are circumferential in the thoracic region. THORACOLUMBOSACRAL (TLS) Wearing these circumferential corsets for at least one hour has been shown to alter the breathing patterns of normal individuals by reducing the tidal volume and increasing the breathing rate. THORACOLUMBOSACRAL (TLS) Another type of soft thoracic orthosis, called a postural training orthosis (PTO) or a weighted kypho orthosis (WKO), This device, designed to be worn like a backpack, This appliance has a pocket located posteriorly at about T10 into which is placed a 1- to 2-lb weight. The orthosis is worn from 30 minutes to 2 hours per day during exercise sessions that focus on trunk extension, balance, and posture. Unlike some spinal orthoses, this appliance is not intended to passively correct the kyphotic deformity through full-time wear.  THORACOLUMBOSACRAL (TLS) Indication osteoporosis, excessive thoracic kyphosis, and balance issues that could lead to falls and fractures. Effect increases its wearer’s perception of spinal joint position or proprioception, improves balance and some gait parameters, increases back extensor muscle strength, reduces back pain. improve daily physical activities.  SACROILIAC ORTHOSES Belts that are worn around the pelvis between the iliac crests and the greater trochanters, although some are a bit wider and extend to the inguinal region or pubic symphysis. Sacroiliac belts are used by patients with back pain that is attributed to sacroiliac joint (SIJ) hypo- or hypermobility. Pregnancy-related pelvic girdle pain and low back pain are commonly associated with SIJ hypermobility. RIGID TRUNK ORTHOSES: Lumbosacral and Thoracolumbosacral Orthoses  RIGID TRUNK ORTHOSES Rigid trunk orthoses were usually constructed from metal or plastic (usually polyethylene) as one piece or multiple pieces connected by straps. Most rigid appliances are prescribed to limit spinal motion, either regionally or segmentally, to protect the spine or facilitate healing. RIGID TRUNK ORTHOSES: Rigid orthoses employ three-point counterforce systems to restrict spinal motion and can be applied in more than one plane in one orthosis. For example, the appliance depicted in Figure restricts sagittal plane (flexion, extension) and frontal plane (lateral bend) movements by placing rigid components where force applications are required to form the three-point counterforce systems. In order to control the lumbar spine effectively with these counterforce systems, an appliance must have sufficient lever arm length to produce effective forces. RIGID TRUNK ORTHOSES: LUMBOSACRAL AND THORACOLUMBOSACRAL ORTHOSES TLSOs are more effective when rotary control of the trunk is important. However, whether a LSO or a TLSO is selected, rigid plastic body jackets are more effective in controlling rotation because their “total contact” design has more contacts to provide three point counterforces in the transverse plane. Pelvic rotation is also difficult to control in a spinal orthosis. In order to affect the pelvis, the orthotic pelvic band or inferior aspect of the body jacket must extend inferiorly as far as possible without interfering with sitting and maintain solid contact with the sacrum and buttocks.  RIGID TRUNK ORTHOSES: Sweating can be a problem when a large surface area of skin is covered by a solid piece of molded plastic. Clinicians can prescribe a T-shirt or body sock interface, drill perforations or holes into the orthosis, or line the orthosis with foam to prevent excessive sweating and skin irritation.  TYPES OF RIGID LUMBOSACRAL ORTHOSES (LSOS) Chairback orthosis LSO, FE control Thoracic, pelvic bands; paraspinal uprights; no lateral uprights Chairback orthosis  TYPES OF RIGID LUMBOSACRAL ORTHOSES (LSOS) Taylor spinal orthosis LSO, FE control Axillary loops for AP forces to limit flexion; posterior spinal upright(s); abdominal apron Taylor spinal orthosis  TYPES OF RIGID LUMBOSACRAL ORTHOSES (LSOS) Knight spinal orthosis LSO, FEL control Thoracic, pelvic bands; paraspinal, lateral uprights Knight spinal orthosis  TYPES OF RIGID LUMBOSACRAL ORTHOSES (LSOS) Anterior overlap body jacket Anterior opening, total contact molded plastic - Clamshell body jacket Bivalved, total contact molded plastic LSO, FELR control Anterior overlap body jacket - Clamshell body jacket  RIGID THORACOLUMBOSACRAL ORTHOSES Goals for use of TLSOs include: o Restricting spinal motion following thoracic spinal surgery o Limiting thoracic flexion or supporting an excessive thoracic kyphosis to minimize thoracic back pain o Preventing the progression of scoliotic curves in certain individuals with adolescent idiopathic scoliosis Typically, the effective range of stabilization in a TLSO is from T5 through L4. Orthoses that are expected to affect spinal segments above T5 require an additional rigid extension to the subclavicular or cervical regions. Type of Rigid Thoracolumbosacral Orthoses (TLSOs) Jewett TLSO, F control Anterior sternal and suprapubic PA forces to limit flexion + posterior pad for PA force Lateral uprights Jewett Type of Rigid Thoracolumbosacral Orthoses (TLSOs) CASH TLSO, F control Anterior sternal and suprapubic PA forces to limit flexion + posterior pad for PA force Cruciform CASH Type of Rigid Thoracolumbosacral Orthoses (TLSOs) Spinomed® TLSO, F control Backpack design; facilitates active postural extension. is used with clients with excessive kyphosis due to osteoporotic compression fractures. It is used to provide feedback to stimulate the active Spinomed correction of posture during exercise as well as functional activities. Type of Rigid Thoracolumbosacral Orthoses (TLSOs) Taylor spinal TLSO, FE control Axillary loops for AP forces to limit flexion; posterior spinal upright(s); abdominal Taylor spinal apron Type of Rigid Thoracolumbosacral Orthoses (TLSOs) Body jackets: Anterior opening Posterior opening Clamshell Sternal, subclavicular extensions TLSO, FELR control Total contact molded plastic; custom-made or custom-fitted prefabricated Body jackets:  SOFT BODY JACKET Some clients who need trunk support may not be able to tolerate a rigid orthosis. In these cases, a soft body jacket may be a better option. Soft body jackets are made from dense foamed polyethylene and are attached to a rigid framework. They are more comfortable than rigid orthoses and can be helpful for individuals with poor muscular control of the trunk.  SCOLIOSIS Thoracolumbar Orthoses for Management of Scoliosis Although scoliosis is typically characterized by its lateral curvatures in the frontal plane, it is actually a three- dimensional spinal deformity. Scoliosis can be structural or functional (flexible). The goal of using a spinal brace in the management of scoliosis in an individual who does not have a neuromuscular disorder is to support the trunk and hold the curve to prevent progression, or worsening, of the curve. Brace are recommended for treatment of individuals with curves that measure between 25° and 45° that have progressed by at least 5° since detection and who have significant growth potential remaining as indicated by largely open growth plates, and in girls, lack of menses. Non-progressing curves and those less than 25° are observed but not treated. Progressive curves that are greater than 45° to 50° are treated with surgery to correct and fuse the spine. Most AIS braces are prescribed to be worn during the day and night, from a minimum of 16 to 18 hours per day to the preferred 23 hours per day. A second group of orthoses, called nocturnal (nighttime) braces, are worn only at night during sleep (8 to 10 hours per day) on at least 5 of 7 nights per week.  MILWAUKEE BRACE (CTLSO) Milwaukee brace, has a superstructure, or one anterior and two posterior uprights that extend from the pelvic mold and are connected at the cervical spine with a neck ring. It is used when the apex of the thoracic curve is superior to T6. The Milwaukee brace is also used to correct excessive kyphosis.  THE BOSTON (TLSO) Boston brace may be custom fabricated from an individual cast or by using computer-assisted design methods. Trimlines are cut on the selected module, based on the child’s x-ray, to provide contact points to apply three- point counterforces for curve correction. Additional pads are added to the inside of the module to focus the counterforces. Voids or reliefs are located opposite to the curve to provide space for active curve correction as the child moves away from the pads. For individuals with a curve apex above T6, a superstructure can be added  THE WILMINGTON TLSO, The orthosis is fit to the patient with inferior trimlines to the level of the greater trochanters and pubic symphysis, and the superior, to fit as high in the axillae as possible. No additional correction pads are added to the inside of the appliance. There is an anterior overlapping opening to facilitate easy donning and doffing.  THE WILMINGTON TLSO, For the best results, clients are encouraged to wear their Boston or Wilmington braces for 23 hours per day. Although some report successful outcomes with brace wear as little as 16 to 18 hours per day, the more time spent in the brace, the more effective it is in preventing curve progression. The location of the pressure pads and how tightly the closures are fastened also affect the brace's efficacy. When skeletal maturity is reached, bracing is discontinued gradually over a year or more to ensure that the curve does not progress.  NIGHTTIME BRACES Nighttime braces are used to treat adolescent idiopathic scoliosis (AIS) in children who do not want to wear braces during the day. They are molded plastic TLSOs that are formed over a cast of the child's trunk while the child is side-bending toward the convexity of the curve. This overcorrection helps to unbend and straighten the Figure 1: The Charleston bending brace is a nocturnal scoliosis brace that applies side-bending forces toward the convexity of the curve (A) to overcorrect the curve (B, C). scoliosis. THE CHARLESTON BENDING BRACE The Charleston bending brace is most effective with single curves with their apices below T7. Figure 1: The Charleston bending brace is a nocturnal scoliosis brace that applies side-bending forces toward the convexity of the curve (A) to overcorrect the curve (B, C). THE PROVIDENCE SCOLIOSIS SYSTEM The Providence scoliosis system is used with a wider range of curves, including double curves. THANK YOU