Spinal orthoses

Definition

Spinal orthoses, also known as braces, are devices worn on the body to treat conditions such as scoliosis , back pain , and injury.

Purpose

Most spinal orthoses are designed to adjust skeletal alignment, limit torso movement, and compress the stomach .

Scoliosis

Spinal orthoses are used to treat longterm spinal conditions such as scoliosis. The brace is worn to stop the progression of scoliosis, which is the lateral (side-to-side) curvature of the spine. This condition progresses as a person grows and is primarily seen in children and adolescents. In general, scoliosis can not be reversed. Therefore, the goal of treatment is stop the progression of scoliosis.

Orthopedists usually diagnosis this condition based on an x-rays showing curves of 10 degrees or more. Treatment is usually indicated when curves measure 25 degrees or more. Scoliosis progresses more slowly as

patients reach skeletal maturity, so use of spinal orthosis is prescribed for patients with at least 18 months of growing left. In older patients, scoliosis is treated with surgery.

Back pain

Spinal orthoses are worn to relieve back pain and to provide back support after an injury or to treat conditions such as degenerative disc disorder. Other uses of spinal orthoses include protecting the back after surgery and the stabilization and support of a weak back.

Description

For more than two thousands years, doctors have tried to treat scoliosis by having patients wear devices to keep their spines rigid. Equipment used throughout the centuries included bandages bolstered by splints, leather appliances, and plaster casts. During the Middle Ages, the craftsmen who made armor for knights also produced bulky metal corsets to stop the progression of scoliosis.

Today, braces made of materials ranging from cotton to plastic are used to treat conditions related to the back and spine. Spinal orthoses vary in size from the cloth belts worn for back support to the rigid full-torso Milwaukee brace used to stop the progression of scoliosis. Braces used to treat scoliosis are prescribed by an orthopedist. The orthosis may be custom-made or fitted from a prefabricated brace.

Corsets and belts

Cloth corsets and belts are generally made of cotton, nylon, or rayon. These flexible orthoses are used to relieve back pain and to restrict movement.

Rigid and semi-rigid spinal orthoses

The braces worn to treat scoliosis or during rehabilitation from spinal surgery are generally classified as rigid or semi-rigid orthoses. The rigid orthosis immobilizes the spine and prevents spinal motion. It is designed to apply force in every direction, distributing pressure over a broad area. A semi-rigid brace combines the support of a rigid brace with the flexibility of a cloth orthosis.

Orthoses for scoliosis

Orthoses prescribed for the treatment of scoliosis generally fall into three categories, with model variations in each group.

THE MILWAUKEE BRACE. The Milwaukee brace is a full-torso orthosis developed during the late 1940s. Named for the location of the doctors who developed it, the orthosis consists of pressure pads held in place by three vertical metal bars. The bars extend from a neck ring, a type of collar worn around the neck. The bars are secured at the neck ring and anchored to a plastic pelvic girdle. The rear vertical bar extends down the back. There are two shorter bars in front.

The neck ring centers the head and straightens the spine. The pads apply pressure to the spinal curve to keep it from worsening. Patients wear the brace under clothing, and it is worn for much of the day. While it effectively stops the progression of scoliosis, wearing the brace with the visible neck ring can be embarrassing for patients.

LOW-PROFILE BRACES. During the 1970s, doctors in Boston developed a brace that extends from under the arms to the hips. Variations of this brace are known as thoracolumbar-sacral orthoses (TLSOs), the Boston brace, the low-profile brace, and the underarm brace. The orthosis consists of a plastic corset with pressure pads attached to the inside. The original braces opened from the back. Current models open in the front or back. However, the back-opening orthosis generally keeps the pelvis in place. This reduces the flattening of the lower back that can occur when scoliosis is treated with an orthosis.

Patients wear the underarm brace for much of the day. This orthosis is regarded as low-profile because it is not visible when worn under clothes.

THE CHARLESTON NIGHTTIME BENDING BRACE. This orthosis developed in 1979 forces the spine to one side. It is held in place away from the direction of the spinal curve. The bending brace is curved and is designed to be worn only at night when the patient sleeps. Most patients have no trouble sleeping in this brace once they have adjusted to wearing it. In addition, many young patients appreciate the option of wearing th brace only at home and going to school without wearing a brace.

Operation

The overall length of time for wearing a spinal orthosis depends on the patient's age and condition. If the brace stops the progression of scoliosis, the patient wears an orthosis until reaching skeletal maturity (around age 15 or 16). The orthopedist or other health professional will determine the amount of wearing time when a brace is used to treat other conditions. While daily wearing times will also vary by the patients, there are set times for how long orthoses should be worn during treatment for scoliosis.

Scoliosis treatment

Orthopedists are divided about how long some spinal orthoses should be worn each day to treat scoliosis. While some doctors believe that the brace must be worn fulltime, others maintain that part-time bracing can be effective. In some cases, this recommendation is based on the patient's condition and age. In other cases, the health care team realizes that young patients embarrassed by the awkward Milwaukee brace may stop wearing it. In these situations, doctors believe that a shorter wearing time or a split schedule could be more effective.

For fulltime bracing to stop the progression of scoliosis, the daily wearing time is:

• 22-23 hours for the Milwaukee brace. The patient can remove the orthosis when bathing. Some doctors allow the patient to remove the brace when exercising; others say that it can be worn while doing some exercises.
• 20 hours for the Boston brace. Daily wearing time of 16 hours may be effective. However, reduced time could increase the risk of curve progression.
• During the eight to nine hours of sleep for the Charleston bending brace.

Precautions

Patients should be told that it takes time to adjust to wearing an orthosis. A light shirt or other article of clothing should be worn under the brace because the appliance should not touch the skin. The health care team should realize that patient compliance is a crucial part of treatment, especially during treatment of scoliosis. Younger patients should be counseled about the importance of their treatment. They should be consulted about the type of orthosis chosen and advised about how to make adjustments to wardrobe so that they feel they fit in.

Furthermore, the patient should be advised to exercise regularly. Exercise helps to preserve spinal motion and keeping adjacent muscles strong.

Maintenance

For scoliosis braces, adjusting the tension on chest straps may be necessary. In addition, the spinal orthosis will need to be adjusted as the patient grows. Generally, a brace needs to be replaced after 15 months.

KEY TERMS

Disc —A circle of cartilage located between vertebrae in the spine.

Torso —The trunk of the human body, the area exclusive of the head and limbs.

Vertebrae —The back bones that form the spinal column. The bones are connected by discs and facet joints.

Health care team roles

Patients are seen by an orthopedist, a physician specializing in the treatment of musculoskeletal disorders. This specialty is concerned with deformities, diseases and injuries of the arms, legs, spine, and associated structures. The physician examines the patient, interprets xrays, and establishes a treatment plan.

If a brace is needed, the patient is sent to an orthotist, an allied health professional who measures, designs, and fits orthopedic equipment like spinal orthoses. Orthotists may supervise several staff members. In some workplaces, the orthotics assistant assists the orthotist and may fabricate, repair, and maintain braces. However, orthoses may be made by the orthotics technician, an allied health worker who takes direction from the orthotist and the orthotics assistant. The technician also repairs and maintains braces. In some settings, the technician may have no contact with patients. Physical therapists will help the patient set up an exercise or rehabilitation program. In addition, a nurse may help plan treatment.

When a patient begins treatment for scoliosis, the orthopedist generally sees the patient several times annually. These appointments are scheduled every four to six months to allow the health care team to assess the patient's growth. The orthotist and orthotic technician may need to adjust a brace or fit a new orthosis. Once the patient is skeletally mature and bracing treatment ends, the patient usually returns a year later for a follow-up assessment that includes an x-rays. The patient may be asked to return in five years. Patients are urged to return if a problem develops or they become pregnant.

Training

Members of the health care team receive training in the use of spinal orthoses while studying for their respective professions. For the orthopedist, this training is part of medical school. For the orthopedic nurse, this training comes during nursing school.

Orthotists earn a four-year bachelor of science degree and finish with specialized orthotic training. They also serve a clinical residency. Orthotics technicians complete programs that last from six months to one year. In addition, people working in these allied health professions can receive certification through the American Academy of Orthotics and Prosthetics . Board certification is based on factors including education, employment, continuing education courses, and membership in the academy.

The name of the academy reflects the relationship between the fields of orthotics and prosthetics. While orthotics usually focuses on temporary treatment with a brace, prosthetics involves permanent replacement of a body part with an artificial appliance. However, some patients will require both prosthetics and orthotics, so schools offer degrees and certificates in both disciplines.

Resources

BOOKS

American Academy of Orthopaedic Surgeons. Edited by Goldberg, Bertram, et al. Atlas of Orthoses and Assistive Devices, 3rd. Ed. St. Louis, MO: Mosby Year Book, Inc.,1997.

Eisenpreis, Bettijane. Coping with Scoliosis. New York: The Rosen Publishing Group, 1998.

Lusari, M. M., and C. C. Nielsen. Orthotics and Prosthetics in Rehabilitation. Boston: Butterworth-Heinemann, 2000.

Neuwirth, Michael and Kevin Osborn. The Scoliosis Handbook. New York: Henry Holt and Co., 1996.

ORGANIZATIONS

American Academy of Orthotists and Prosthetists. 526 King Street, Suite 201, Alexandria, VA 22314. (703) 836-0788. <http://www.oandp.org>.

American Board for Certification of Orthotics and Prosthetics. 330 John Carlyle Street, Suite 200, Alexandria, VA 22314. (703) 836-7114. <http://www.opoffice.org>.

American Orthopaedic Association, 6300 N. River Road, Suite 505, Rosemont, IL 60018. (847) 318-7330. <http://www.aoassn.org>.

National Association of Orthopaedic Nurses, P.O. Box 56, Pitman, NJ 08071. (856) 256-2310. <http://www.naon.nurse.com>.

Liz Swain