Disclosure
An orthotic device (commonly just referred to as an orthotic) is an external device applied on the body to limit motion, correct deformity, reduce axial loading, or improve function in a certain segment of the body. Design characteristics of an orthotic device are crucial to function. Most important features include the following:
Indications for recommending orthotic devices include the following:
Duration of orthotic use is determined by the individual situation.
Use of an orthotic device is associated with several drawbacks, including the following:
Success of the orthosis may lead to any of the following:
Physicians must understand the biomechanics of the spine and each individual orthosis. The cervical spine is the most mobile spinal segment with flexion greater than extension. The occiput and C1 have significant flexion and extension with limited side bending and rotation. The C1-C2 complex accounts for 50% of rotation in the cervical spine. The C5-C6 region has the greatest amount of flexion and extension. The C2-C4 region has the most side bending and rotation. When compared to the cervical and lumbar spine, the thoracic spine is the least mobile. The thoracic spine has greater flexion than extension. Lateral bending increases in a caudal direction, and axial rotation decreases in a caudal direction. The lumbar spine has minimal axial rotation. The greatest movement in the lumbar spine is flexion and extension. Immobilization of the spine increases erector spinae muscle activity since normal rotation that occurs with ambulation is limited by the orthosis. The biomechanical principles in orthotic design include balance of horizontal forces, fluid compression, distraction, construction of a cage around the patient, placement of an irritant to serve as a kinesthetic reminder, and skeletal fixation. Construction of a cage around the patient, like a thoracolumbar brace, increases intraabdominal pressure. Increased intraabdominal pressure converts the soft abdomen into a semirigid cylinder, which helps to relieve part of the vertebral load. In general, structural damage to posterior elements of the spine creates more instability with flexion, whereas damage to anterior elements creates more instability with extension. Orthotic devices (orthoses) are generally named by the body regions that they span. For example, a CO is a cervical orthosis, while a CTLSO is a cervicothoracolumbosacral orthosis, spanning the entire length of the spine. Many of these devices are also known by eponyms.
Several drawbacks to cervical orthotic (CO) use have been noted. The soft tissue structures around the neck (eg, blood vessels, esophagus, trachea) limit application of aggressive external force. The high level of mobility at all segments of the cervical spine makes it difficult to restrict motion. Cervical orthoses offer no control for the head or thorax; therefore, motion restriction is minimal. Cervical orthoses serve as a kinesthetic reminder to limit neck movement. Observe appropriate precautions associated with orthotic use. Keep in mind that continued long-term use has been associated with decreased muscle function and dependency. The soft collar (see Image 1) is a common orthotic device made of lightweight material, polyurethane foam rubber, with a stockinette cover. It has Velcro closure strap for easy donning and doffing. Patients find the collar comfortable to wear, but it is soiled easily with long-term use. The average soft collar costs $50. Indications for use of the soft collar include the following benefits for the patient:
The soft collar provides some limitations of motion for the patient, including the following:
The hard cervical collars are similar in shape to a soft collar but are made of Plastizote, a rigid polyethylene material shaped like a ring with padding. Height can be adjusted in certain designs to fit patients better. Velcro straps are used for easy donning and doffing. The hard collar is more durable than a soft collar with long-term use. A hard collar costs approximately $60. Several problems can be alleviated with use of a hard collar. The indications include the following:
Motion restrictions for the hard collar include the following:
Head cervical orthotics (HCOs) include the occiput and chin to decrease range of motion (ROM). Supported chin area is a common place for skin breakdown and ingrown hair for men. The clavicle is another area for skin breakdown and discomfort with HCOs. HCOs generally are used in stable spine conditions. Like in the case of cervical orthotics, continued long-term use of HCOs has been associated with decreased muscle function and dependency. The Philadelphia collar (see Image 4) is a semirigid HCO with a 2-piece system of Plastizote foam. Plastic struts on the anterior and posterior sides are used for support. The upper portion of the orthosis supports the lower jaw and occiput, while the lower portion covers the upper thoracic region. The Philadelphia collar comes in various sizes and is comfortable to wear, improving patient compliance. Velcro straps are used for easy donning and doffing. The Philadelphia collar is difficult to clean and becomes soiled very easily. An anterior hole for a tracheostomy is available. A thoracic extension can be added to increase motion restriction and treat C6-T2 injuries. Average cost for a Philadelphia collar is $125. Motion restrictions for the Philadelphia collar include the following:
The goal of the Philadelphia collar is to provide immobilization and is indicated after the following:
The Miami J collar (see Image 2) is another cervical orthotic device in common use. The Miami J collar has a 2-piece system made of polyethylene and a soft washable lining. The anterior piece has a tracheostomy opening similar to that in the Philadelphia collar. Velcro straps provide easy donning and doffing. The Miami J collar is a semi-rigid HCO. A thoracic extension can be added to increase support and treat C6-T2 injuries. The Miami J collar is available in various sizes and can be heated and molded to a contoured fit. Average cost for a Miami J collar is $150.
Motion restrictions with the Miami J collar include the following:
Indications for use of a Miami J collar are the same as the Philadelphia collar. (See indications for Philadelphia collar.)
The Malibu collar (see Image 3) is similar to the Philadelphia collar as it is a semi-rigid orthosis designed in a 2-piece system with an anterior opening for a tracheostomy. The Malibu collar comes in only one size, but it is adjustable in multiple planes to ensure proper fit. Anterior chin support height is also adjustable. Straps around the chin, occiput, and lower cervical area provide for tightening. Padding around the chin can be trimmed to ensure proper fit. Thoracic extension can be added to increase support and treat C6-T2 injuries. Average cost for a Malibu collar is $160-200.
Motion restrictions for the Malibu collar include the following:
Indications for use of a Malibu collar are similar to those for the Miami J and Philadelphia collars. (See indications for Philadelphia collar.)
The Aspen Collar has a 2-piece system made of polyethylene with soft foam liner with an anterior opening for a tracheostomy. The Aspen collar is a semi-rigid HCO with Velcro straps for easy donning and doffing. The Aspen collar costs approximately $160.
Motion restrictions mirror those of the Miami J collar and include the following:
Indications for use of the Aspen collar include the same as the HCOs discussed above. (See indications for Philadelphia collar.)
The Jobst Vertebrace is made of high-density polyethylene with soft polyethylene foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for use in emergent transport situations, and it is similar to the Yale or Philadelphia collar in restricting motion. The Jobst Vertebrace provides full contact along its costal ends to the sternum and cradles the mandible for stability. The Jobst Vertebrace costs approximately $150.
Motion restrictions for the Jobst Vertebrace are similar to those of the Yale and Philadelphia collars, including the following:
Indications for use of the Jobst Vertebrace are similar to those for the Miami J and Philadelphia collars. (See indications for Philadelphia collar.) |
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Cervical thoracic orthotics (CTOs) provide greater motion restriction in the middle to lower cervical spine from the added pressure on the body. The upper cervical spine has less motion restriction. CTOs are used in minimally unstable fractures. The Sternal-Occipital-Mandibular-Immobilizer (SOMI) (see Image 5) is a rigid three-poster CTO with anterior chest plate that extends to the xiphoid process and has metal or plastic bars that curve over the shoulder. Straps from the metal bars go over the shoulder and cross to the opposite side of the anterior plate for fixation. A removable chin piece attaches to the chest plate with an optional headpiece that can be used when the chin piece is removed for eating. The two-poster CTOs start from the chest plate and attach to the occipital component. The SOMI is ideal for bedridden patients since it has no posterior rods. The SOMI is relatively comfortable to wear. Proper adjustment is crucial for motion restriction; in fact, motion restriction may be minimal with incorrect application. The SOMI is less effective compared to other braces in controlling extension, but it is very effective in controlling flexion at the atlantoaxial and C2-C3 segments. The SOMI is better than the cervicothoracic brace in controlling flexion in the C1-C3 segments. Average cost for a SOMI brace is $480. Indications for use of the SOMI include the following:
Motion restrictions with the SOMI include the following:
The Yale orthosis is a modified Philadelphia collar with thoracic extension made of fiberglass extending anteriorly and posteriorly with mid-thoracic straps on the sides connecting the 2 thoracic extensions. The thoracic component helps to treat C6-T2 injuries. The occipital piece extends higher up on the skull posteriorly. Increased contact surface area improves stability of the brace. Patients find the Yale orthosis comfortable to wear. The Yale orthosis is easy to fabricate and costs approximately $320. Various indications for use of the Yale orthosis include the following:
Motion restrictions for the Yale orthosis include the following:
The four-poster brace is a rigid orthosis with anterior and posterior chest pads connected by a leather strap. Molded occipital and mandibular support pieces connect to the chest pads and have adjustable struts. Straps connect the occipital and mandibular support pieces. The mandibular plate can interfere with eating. This brace uses shoulder straps, but it has no underarm support. Open design allows heat loss from the neck. The brace is as effective as the cervicothoracic brace in controlling flexion in the mid-cervical area and is better than the Philadelphia collar. The four-poster design limits lateral bending and rotation better than the two-poster brace. The four-poster brace costs approximately Motion restrictions provided by the four-poster orthosis include the following:
The Guilford brace is a rigid CTO with a two-poster design with anterior chest plate and shoulder straps that connect to the posterior plate. Chin plate and occipital piece connect to the anterior and posterior struts. Underarm straps circle the lower chest wall for stability. The brace has poor control of flexion, extension, rotation, and lateral bending at C1-C2. The Guilford brace costs approximately $610.
Motion restrictions afforded by the Guilford brace include limitation of flexion and extension from C3-T2.
Indications for use of the Guilford brace include the following:
The halo device (see Image 6) is the most common device for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3. The halo provides maximum motion restriction of all cervical orthotics. The halo ring is made of graphite or metal with pin fixation on the frontal and parietal-occipital areas of the skull. Development of lightweight composite material led to design of radiolucent rings compatible with magnetic resonance imaging (MRI). The halo ring attaches to the vest anteriorly and posteriorly via 4 posters.
The halo vest has shoulder and underarm straps for tightening and usually is made of rigid polyethylene and extends down to the umbilicus. Restriction in cervical motion depends on the fit of the halo vest since improper fit can allow 31% of normal spine motion. The halo vest is the weak link in terms of motion control. Compressive and distractive force can occur with variable fit of the vest.
Multidirectional shear forces can cause increased pinhole size with craterlike enlargement. Pin loosening occurs twice as frequently with a heavier halo vest. Generally, upper cervical spine injuries are treated best with a full-length vest to the iliac crest. Average cost of the halo device with vest is $2800.
Indications for use of a halo device are for immobilization in the following cases:
Contraindications for use of the halo device include the following:
The relative contraindications for use of the halo device include the following:
The application process for the halo device consists of several steps. Optimal placement for the anterior pins is the anterolateral aspect of the skull 1 cm above the orbital rim on the lateral part of orbit since this prevents penetration into the orbit. Avoid placing pins in the temporalis muscle and through the zygomaticotemporal nerve, which supplies sensation to the temporal area. Pins inserted into the temporalis muscle affect mandibular motion and cause pain. Placement away from the medial one third on the orbital rim preserves the supraorbital and supratrochlear nerves and decreases risk of entering the frontal sinus.
Insertion of posterior pins on the posterolateral aspect of the skull is less crucial. Skin incisions are not necessary prior to pin placement. The halo ring should be 1 cm above the top of the ear. Place all pins perpendicular to the skull, and allow 1-2 cm clearance with the halo ring along the skull perimeter.
In adults, pin insertion requires a torque wrench set at 8 inches per pound since this lowers incidence of pin infection and loosening. In children, set the torque wrench between 2-5 inches per pound since the skull is too weak to sustain heavier forces. Use multiple pin sites in children because of the weaker skull.
Determine the halo vest size by measuring chest circumference at the xiphoid process. Elevate the patient at 30-40° for vest placement. Secure the posterior portion to the halo first, then to the anterior part of the vest. Tighten the bolts on the vest to a torque setting of 28 feet per pound. Tools for the vest sometimes are taped to the anterior part of the vest in case of emergency.
At 24-48 hours after placement, recheck all pins for loosening. Clean the pin sites with saline or soap and water on a sterile swab. Take x-rays immediately after halo placement and after any adjustment to check spinal alignment. Shaking of the cervical spine because of forced movement against the orthosis or changes in pin tightening can cause some segmental motion. Symptoms of dysphagia may result from placement of the neck in too much extension. Repositioning of the halo, if possible, can eliminate dysphagia.
Motion restrictions provided by the halo include the following:
Various complications associated with halo placement include the following:
In use of the halo device, keep in mind the following important considerations:
The best orthotic device to control various cervical regions is indicated as follows:
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 (see Image 8) features 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:
Motion restrictions provided by the CASH brace include the following:
Contraindications to use of the CASH brace include the following:
The Jewett hyperextension brace (see Image 7) 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:
Motion restrictions provided by the Jewett brace include the following:
Contraindications to use the Jewett brace include the following:
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:
Motion restrictions and contraindications of the Korsain brace are similar to the Jewett brace. (See Jewett brace motion restrictions.)
The Knight-Taylor brace features 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 include the following:
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:
Motion restrictions for the TLSO include the following:
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.
The chairback brace (see Image 10) 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 include the following:
Motion restrictions of the chairback brace include the following:
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. (See indications for chairback brace.)
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 include the following:
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. (See indications for 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 include the following:
Motion restrictions of the Standard LSO corset include limitation of flexion and extension. The rigid LSO (see Image 9) 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 include the following:
Motion restrictions provided by the rigid LSO brace include the following:
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:
Motion restrictions of the rigid LSO with hip spica include the following:
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.
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:
The clinician must take into account several bits of clinical information about use of braces in scoliosis including the following:
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 include the following:
Duration of the Milwaukee brace use is determined by the following criteria:
Side effects of the Milwaukee brace include the following:
Failure to correct deformity can be caused by any of the following:
Keep in mind clinical information regarding use of the Milwaukee brace, including the following:
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 include the following:
Side effects associated with use of the Boston brace include the following:
Certain preventive measures can reduce difficulties associated with use of the Boston brace, including the following:
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:
Duration of Boston brace use is determined by several factors, including the following:
Clinical information relevant to use of the Boston brace includes the following:
The Charleston bending brace 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 include the following:
Clinical information regarding use of the Charleston bending brace includes the following:
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