SU_Back_Braces

					A Patient’s Guide to Back Braces

Introduction

Bracing has been used for hundreds of years to correct or control the
spine. Early reports of treatment for <i>scoliosis</i> (curvature of the spine)
indicate that chest straps and metal corsets were once used. Over time, the
materials used for spinal braces have changed from an iron to plaster to
leather and more recently, plastic. Another word for brace is <i>orthotic</i>.

Spinal braces come in all sizes and shapes. There are two basic types of
back braces: <i>corrective</i> and <i>immobilizing</i>. Corrective braces
straighten the spine, whereas immobilizing orthotics hold the spine in place.
Spinal braces are designed to control spinal motion while increasing your
function and decreasing rehabilitation time. The surgeon or prescribing
physician decides if the goal is to correct spinal alignment or immobilize the
spine. Correction is more likely to be the goal with children and teens.


Who Can Benefit?

There are many conditions affecting children, adolescents, and adults that
may require bracing. Spinal cord injury, neuromuscular diseases, sports
injuries, vertebral fractures, and spondylolisthesis are just a few of these
conditions. Bracing or orthotic use can influence recovery for stroke
patients and injured athletes. Adults with degenerative spine conditions
(spinal stenosis, osteoporosis) or disc disease (bulging or herniated discs)
may also benefit.

Bracing may be part of an overall conservative treatment plan to avoid or
delay surgery. When used appropriately, a corset or orthotic can assist in
the healing process. Preventing motion can stop spinal movement that may
be making the inflammation worse and help promote healing of the soft
tissues.

Spinal conditions such as <i>spondylolisthesis</i>, <i>Scheuermann’s
disease</i>, or <i>scoliosis</i> can be stabilized with bracing.
Spondylolisthesis occurs when a fracture of a supporting column of the
vertebra allows the vertebral body to slip forward. The forward pull of the
bone puts traction on the spinal cord and spinal nerves. Scheuermann’s
disease is a forward curvature of the thoracic spine causing a stooped
forward posture. Scoliosis is an abnormal curvature of the spine causing
the normally straight spine to assume a C or S-shape. The goal of bracing
in these conditions is to keep the spinal alignment from getting worse,
prevent deformity, and prevent or delay the need for surgery.

Many patients are simply seeking relief from years of pain and discomfort
from mechanical low back pain. Older adults who have spinal conditions
that limit their freedom of movement are also good candidates. A properly
fit orthoses can offer you a dramatically improved quality of life. It is not a
cure, however, and can mask serious problems. Spinal bracing should
never be used without a physician’s approval.

Some braces allow patients to exercise earlier in the rehabilitation process.
This is especially important for athletes who may lose ground with inactivity
and immobility.

Many people wear soft, elastic corsets that wrap around the low back in an
effort to prevent back injury. These corsets are often worn with shoulder
straps to hold them in place. Since most corsets of this type tend to slip up
off the hips and more toward the waist, the shoulder straps are of no
benefit. Studies show clearly that trying to prevent injury by using support
of this type does not work. The corset may help remind workers of proper
lifting techniques but serve no other purpose.

How They Work

Most spinal orthotics work on the basis of a three-point pressure principle
to stabilize and/or correct the spinal level in question. Less often, a four-
point system of pressure is used. The forces are applied on opposite sides
of the spine from either the front and back of the trunk or from each side.

By limiting or stopping motion, pain is controlled and the spine is unloaded.
Braces can also apply pressure needed to prevent swelling in the muscles
and other soft tissues. The brace can even help tense muscles relax by
creating heat, pressure, and a massage-like effect.

The goal is always to minimize the amount of bracing while targeting what
needs to be stabilized. If the surgeon wants to take pressure off the
vertebrae, then intracavity pressure is used. Intracavity or intraabdominal
pressure refers to braces that put pressure along the front of the abdomen,
pushing the belly in and up toward the spine.

This is called <i>unweighting</i>, <i>unloading</i>, or
<i>decompression</i> of the spine. Increased intraabdominal pressure also
reduces the tension on the spinal muscles and takes pressure off the discs
between the vertebrae.

The surgeon will determine the need for a brace and let the <i>orthotist</i>
(brace maker) know if the purpose of the brace is to reduce motion or stop
motion altogether. The surgeon also communicates what spinal level needs
bracing. Using this information, the orthotist is able to determine what kind
of brace and pressure points would work best.


What They Are Made Of

The principles of bracing haven’t changed over the years, but new
materials such as carbon graphite, special foams, and thermoplastics are
now available. Fiberglass materials, new plastics, and heat-molded panels
that can be slipped inside a corset have made a big difference in who can
be helped with today’s braces.

Orthotics can be made of soft materials such as canvas and foam or they
can be rigid made out of hard or flexible plastic. Some braces use a
combination of both soft and rigid materials. The decision as to which type
is used is based on whether the goal is to reduce or stop motion. Soft
orthotics are used most often when the goal is to reduce but not prevent
motion. Rigid orthotics are saved for patients who must limit motion or not
move at all. The goal is always to maximize stability while preserving
overall function with minimal bracing.

If it’s not clear where the problem is coming from, the surgeon may request
a rigid brace to start. By over bracing, the patient may obtain temporary
relief of painful symptoms. In such cases, the brace is used as a diagnostic
tool. Patients wear the brace for six to eight weeks. Then the surgeon re-
assesses them to see how they responded. Good pain relief may be a sign
that surgery to fuse the bones and permanently stabilize the lumbar spine
is indicated.
Bracing may be used following surgery in some cases. For postoperative
patients, a new design of orthosis with built-in air cells controls is available.
The orthosis provides the amount of compression needed while avoiding
direct contact with the incision site.

Types of Spinal Bracing

There are many different kinds of braces with all levels of support and
control to increase stability of the lumbar spine. They may support just the
low back (lumbrosacral) area. These are called <i>lumboscral orthoses</i>
(LSOs). Or they may extend up the thoracic spine for higher control called
<i>thoracolumbar sacral orthoses</i> (TLSO).

They may be prefabricated and available in several sizes that can be fitted
to you. Or they may be custom made by an orthotist who makes a mold of
your body and then shapes materials to fit you exactly. Every effort is made
to provide you with a brace that fits and is easy to put on and take off. Best
results occur when the proper brace is selected and the patient consistently
follows the program of wearing and exercise.

Corsets

Corsets restrict or limit but do not prevent all spinal motion. The main goal
of a corset is abdominal compression. EMG studies show that corsets do
not significantly alter muscle activity of the main spinal muscle: the
<i>erector spinae</i>.

Corsets come in different sizes to fit various body shapes, different waist-
to-hip ratios, and different patient heights. There are two basic types of
corsets. The <i>traditional</i> corset is made of canvas with lace up sides
and Velcro straps to secure the corset in place. Two metal stays are
shaped according to your needs and slipped inside vertical panels along
either side of the spine.

The <i>wrap around</i> corset is an elastic binder with Velcro straps to
hold it in place. Sometimes these are referred to as <i>abdominal
binders</i>. This type of corset works well for patients with a large
abdomen or pear-shaped figure. It is less likely to slide up over the hips to
the waist.
The wrap around corset has a thermoplastic panel that can be heated and
shaped to provide stability over the lumbar spine where it is needed most.
The plastic insert is slipped inside a back panel in the corset and molded to
the patient’s body while it is still warm. It can be reheated and remolded as
many times as needed. At first the orthotist may use the corset to hold the
spine in a position known to provide pain relief. Over time the panel can be
reshaped to realign the spine more normally.

Body Jacket

When support and control of both the thoracic, lumbar, and sacral spine are
needed, a body jacket may be used. These are referred to as
<i>thoracolumbosacral orthoses</i> (TLSO). The TLSO is a <i>bivalve</i>
rigid body jacket which means it comes in two parts (front and back). It
works like a removable cast for the trunk.

Another name for the bivalve jacket is a clamshell orthosis (CSO). The
material is made of a rigid but flexible plastic. This means you can bend the
plastic when you are holding it in your hands but once it’s on the body, it
stabilizes the spine in all directions. No motion occurs inside the brace.

The flexible plastic can be trimmed down if the patient’s shape or size
decreases. For example, edema after an injury may be present when the
patient is first measured for the brace. As healing occurs, the
intraabdominal or interspinal swelling may resolve. Or the patient may lose
body weight from inactivity while in the brace. Then the brace becomes too
large and must be modified. The brace can also be adjusted for mild
weight gain for any reason. Soft plastic extenders can be added on either
side of the clamshell.

Milwaukee Brace

The <i>Milwaukee Brace</i> is a corrective brace used with children and
adolescents who have scoliosis. It has a pelvic girdle, two posterior
uprights, one anterior upright, and a ring around the base of the skull that
also supports the lower jaw. Originally made of leather and metal, it has
been revised now and is constructed out of rigid plastic with metal uprights.
Straps attached to the frame are used to apply corrective forces.
The Boston Brace

The <i>Boston Brace</i> is very similar to the Milwaukee orthosis used for
the treatment of scoliosis. The Boston brace does not extend up as high
into the thoracic spine. It does not have the vertical bar in front of the chest
or the cervical ring. The Boston brace works best for children who have
immature spines or moderate scoliotic curves in the lower thoracic and
upper lumbar spines.

Hyperextension Braces

The <i>thoracic extension</i> brace is a lumbar support with a vertical
extension bar to help the patient avoid forward motion. Another name for
this type of orthosis is the <i>thoracolumbosacral flexion, extension control
(TLS FE) orthosis. Motion is restricted from T6 to L1.

The TLS FE orthosis offers maximum support while limiting some trunk
motion. Although flexion and extension are restricted, side bending and
rotation are not controlled. Hyperextension braces can be used with older
adults who have <i>kyphosis</i> from osteoporosis. Kyphosis is a forward
curved spine, which causes a forward stooped posture and pressure on the
front of the vertebrae.

There are several common hyperextension braces for the lumbar spine
including the Jewett brace, the CASH brace, the Taylor brace, and
chairback brace. The idea is to restrict flexion of the low back by holding
the thoracic spine in extension.

The <i>Jewett</i> brace is an extension or hyperextension orthosis
designed to stop flexion in the thoracic spine. It works by the same principle
of three-point pressure – in this case the pressure is applied anteriorly
across the chest. The three points of pressure are applied above and below
the unstable portion of the spine and from behind.

The Jewett brace can be used postoperatively to stabilize the spine after
thoracolumbar fractures or for relief from pain of vertebral compression
fractures in patients who do not have osteoporosis.

<i>Cruciform Anterior Spinal Hyperextension</i> CASH brace is another
extension or hyperextension orthosis that has gained in popularity over the
last few years. It still offers the same three-point pressure as the Jewett
brace but patients find its form and fit more comfortable. The CASH brace
may not offer as effective spinal stabilization as the Jewett brace.

The <i>Taylor</i> brace or <i>Knight-Taylor brace</i> has a pelvic band, a
pair of posterior upright bars on either side of the spine, an abdominal front
or corset, a band across the mid back, and straps to go around the
shoulders and under the armpits. The abdominal corset is made of canvas
and provides intracavitary pressure.

Lumbosacral Orthosis

The<i>Knight spinal orthosis</i> or <i>Knight brace</i> is an LSO used to
restrain or prevent flexion, extension, and lateral motion. The brace has a
curved pelvic band to support the buttocks and a thoracic band across the
mid back. The bands are usually leather covered metal but can also be
made of foam-lined rigid plastic. There are a pair of metal uprights on either
side of the spine and another pair along side the torso. A canvas corset
stretches across the abdomen with straps that fasten on one side or the
other.

A newer, more up-to-date version of the Knight brace is called a
<i>lumbrosacral flexion-extension-lateral control </i> (LS FEL) orthosis.
The orthosis is made of polyethylene (rigid plastic) lined with foam. This
type of plastic lumbosacral jacket restricts spinal motion in all directions.
The LS FEL has been shown to work well at controlling spondylolisthesis.

For patients with one or more bulging discs, a different type of LSO is
available. Made of rigid thermoplastic, this brace applies pressure from the
front to give abdominal lift while also applying a traction force on the spine.
The result is a contraction of the diaphragm and spinal muscles. MRI
studies show this type of lumbosacral brace is effective in reducing disc
protrusion.

The <i>chairback</i> brace is a rigid short immobilizing LSO used for
conservative care for pain relief from low back pain and to unload the
intervertebral discs. It is popular because it’s more comfortable and easy to
put on and wear than the longer braces that go all the way up the thoracic
spine. This type of LSO limits flexion and extension at the L1-4 level. It
gives moderate control over side bending in the thoracic spine and only
minimally limits spinal rotation.

The chairback brace has two posterior uprights with thoracic and pelvic
bands. There is an abdominal apron with straps in front that can be
adjusted to increase intracavitary pressure. The pelvic band is placed as
low as possible without interfering with sitting comfort. The posterior
uprights are plastic or metal and go up along both sides of the spine over
the paraspinal muscles.


Sacroiliac Belt

A <i>sacroiliac (SI) belt</i> may be used to stabilize the sacroiliac joint
after an injury or during an acute flair-up from a chronic problem with
hypermobility. Hypermobility means the surface of the joint moves too
much. This can cause pain or tenderness from inflammation. An SI belt
may be indicated after fracture of the pelvis or disruption of the
<i>symphysis pubis</i>. The symphysis pubis is the cartilage joint where
the pelvic bones come together in the front.

Direct compression is used to immobilize the SI joint giving it time to heal.
Newer, improved SI belts can apply a customized amount of pressure to
the sacroiliac region. Adjustable straps allow the belt to cinch together with
just the right amount of pressure to support the joints without over
compressing the hips and pelvis.

There are many brands of SI belts on the market. Your therapist or doctor
will make sure your chosen belt conforms to the natural contours of your
pelvis while still providing the rigid support the sacroiliac joint needs. There
may be an extra pad pressed up against the sacrum to provide
proprioceptive input. Proprioception is the sense of where your body is as
you move. It is the awareness of where your spine is in relation to the rest
of your body and vice versa.

Special maternity SI belts are available for women to use during pregnancy
when SI instability becomes a problem.

What Should I Expect?
Once the physician prescribes the brace, an orthotist will measure you,
make the brace, and fit it to you. Certified orthotists are highly trained
clinicians providing custom-fit or custom-made orthoses. Some corsets and
braces are prefabricated and are referred to as <i>off the shelf</i>. The
orthotist still custom fits this to each patient based on size, shape, and
individual body differences.

The brace is worn under the clothes over a tight fitting t-shirt or other thin,
protective piece of clothing. There must be no wrinkles or lumpy material to
avoid skin pressure and sores. Loose fitting clothes over the brace can
often hide the brace completely. You should inspect your skin carefully at
least once a day for any red marks. Use a mirror to check areas you cannot
see directly or ask a friend or family member to look for areas of redness or
other skin changes. Report any areas of skin irritation to the orthotist that
do not disappear within 30 minutes to an hour.

You may experience immediate pain relief though it may not be total pain
relief at first. Muscle soreness is common as the body adjusts and adapts
to the change in position and movement (or lack of movement). You will
probably feel a sense of improved trunk control, which will help you relax
further reducing pain caused by muscles trying to stabilize the spine by
excessive contraction and holding patterns.

Depending on the type of brace used, the surgeon or physical therapist will
help you develop what’s called a <i>tolerance schedule</i>. It takes several
days up to several weeks to build up how much time you can wear a rigid
TLSO or body jacket. There may be small areas where too much pressure
causes the skin to turn red. It’s important to watch for these spots to avoid
having them develop into pressure sores.

Your surgeon will tell you how often and when to wear the brace. It’s likely
you’ll be wearing the brace at least eight hours a day (usually longer).
Sometimes a common sense approach is used. You may not need bracing
when you are lying down or sitting quietly. You may be advised to wear the
brace anytime you are loading the spine such as when standing, walking,
lifting, or working in any capacity. You should not ride in a car or drive
unless your doctor gives you permission to do so.

In some cases, patients may wear the brace at all times, even when
bathing or swimming. The orthotist will use materials that either are safe to
get wet or can be replaced or dried out easily. For example, closed cell
foam that doesn’t absorb water may be used to line the brace. Extra straps
can be sent home with you to use while the wet straps are drying.

You should never make adjustments to your brace unless told to do so by
your surgeon or orthotist. Even a small adjustment could put you at risk for
skin pressure or change the pressure points needed for spinal control.
Always keep your brace away from the heat of radiators, space heaters,
oven tops, and so on.

It is likely that you will be shown how to do exercises at home while
wearing the brace. A good trunk rehab program is essential. The goal is to
stabilize the spine, increase trunk control, and improve balance. Postural
exercises will begin from the start and continue even after the brace has
been discontinued.

Bracing is not meant to be permanent. Preventing unwanted motion while
supporting and protecting the spine during healing is the primary goal. With
a good rehab program, you should regain muscular and
<i>proprioceptive</i> control of the trunk. Remember, proprioception is the
sense of where your body is as you move. It is the awareness of where
your spine is in relation to the rest of your body.

When it’s time, the therapist will help you wean yourself away from using
the brace. The right time to do this is determined by your surgeon through
the aid of imaging studies such as X-rays and MRIs. You will probably be
advised to use the brace if you have any setbacks. You won’t have to start
the tolerance schedule over again but you may have to wean yourself off
the brace again when it’s no longer needed.

How Do I Care For My Brace?

Any plastic parts of the brace can be kept clean with a warm wet cloth. The
surface should be wiped down daily to remove any dirt or body oil. Do not
use a blow dryer or hair dryer to speed up drying. Any heat source can melt
the foam and soften the plastic.

Check the brace carefully at least once a week for any cracks. Immediate
repair is needed for any cracks or other damage noted. Velcro straps can
get clogged up with hair, bits of thread, and lint. This can keep you from
getting a proper fit. You can use a pin or needle to pull the threads out of
the Velcro hooks.

Leather bands must be kept clean and soft. Leather saddle soap works well
for this purpose. If the leather breaks down enough to see metal
underneath, it’s past time to see your orthotist for new leatherwork. Loose
screws and joints or locks that do not work smoothly and quietly may need
your orthotist’s attention. Make a follow-up appointment as soon as you
notice any problems.




References:
William H. O’Grady, MA, PT, OCS, MTC,COMT, FAAOMPT, O Brother!,
and Michael F. Tollan, PT, OCS. Bracing for Lumbar Instabilities. In
<i>Orthopaedic Physical Therapy Clinics of North America</i>. December
1999.

Susan B. O’Sullivan and Thomas J. Schmitz: Physical Rehabilitation.
Philadelphia, F.A. Davis, 2007.

American Academy of Surgeons: Atlas of Orthotics, 2nd ed. St. Louis,
Mosby, 1985.

Larry Williams, Missoula Orthotics and Prosthetics, Missoula, Montana.

Shantanu S. Kulkarni and Sam Ho: Spinal orthotics. Emedicine, September
2005. Available at:
http://www.emedicine.com/pmr/topic173.htm#section~head_cervical_orthotics.