1. Presented by: Dr.S.Sadeqi PM&R resident of SBUM Jan 2013

2. History of Spinal Orthotic Management The first evidence of the use of spinal orthoses can be traced back to Galen (131 to 201 AD). Primitive orthotic devices were made of items that were readily available during this period: leather, whalebone, and tree bark. Ambroise Pare (1510 to 1590) wrote about bracing and spinal supports, and Nicholas Andry (1658 to 1742) coined the term orthopaedia, pertaining to the straightening of children.

3. Technology has revamped the field of orthotics, with new stronger and lighter materials. Although materials available for orthotic construction have changed, the types of pathologic conditions treated have remained virtually constant for years. The primary goal of modem orthoses is to aid a weakened muscle group or correct a deformed body part. The clinician's priority should be to determine which spinal motion to control.

4. Terminology Orthosis: A singular device used to aid or align a weakened body part Orthoses: Two or more devices used to aid or align a weakened body part. Orthotics: The field of study of orthoses and their management . Orthotic: An adjective used to describe a device. Orthotist: A person trained in the proper fit and fabrication of orthoses .

5. Some Acronyms examples of spinal orthoses follow: CO: Cervical orthosis CTO: Cervicothoracic orthosis CTLSO: Cervicothoracolumbosacral orthosis TLSO: Thoracolumbosacral orthosis LSO: Lumbosacral orthosis SO: Sacral orthosis

6. Prefabricated Versus CustomOrthoses The availability of prefabricated orthoses today presents the rehabilitation team with a variety of choices and some challenges. Many of the prefabricated orthoses come in various sizes and can be fitted to patients often with little or no adjustment. While this can be a benefit to the patient and the team in terms of time, care should be taken to ensure that the design and function of these orthoses are appropriate for the patient's condition and not used purely for convenience. Custom orthoses, in most cases, provide a more comfortable fit with a higher degree of control, and can be designed to accommodate a patient's unique body shape or deformities.

7. Orthotic Prescription Prescriptions should include the following items: Patient's name, age, and gender , Current date Date the orthosis is needed Vendor's name , Diagnosis Functional goal , Orthosis description Precautions Physician's name and unique physician identifier number Physician's signature with office address and contact phone number. Brand names and eponyms for the orthosis should be avoided. Established acronyms are acceptable

8. Detailed descriptions of the orthosis, the joints involved, and the functional goals are important. For a nonarticulated orthosis the fixed angle should be indicated. For an orthosis with a moveable joint, the range of motion desired, end limitations of range, and assistance (or resistance) through the range should be specified. Knowledge of the patient's medical condition is essential for a number of reasons. For example, the condition might be progressive, with further expected functional loss.

9. Normal Spine Biomechanics Movement of the vertebral column occurs as a combination of small movements between vertebrae. The mobility occurs between the cartilaginous joints at the vertebral bodies and between the articular facets on the vertebral arches. Range of motion is determined by muscle location, tendon insertion, ligamentous limitations, and bony prominences.

10. In the cervical region, axial rotation occurs at the specialized atlantoaxial joint. At the lower cervical levels, flexion , extension and lateral flexion occur freely. however, the articular processes, which face anteriorly or posteriorly, limit rotation. In the thoracic region, movement in all planes is possible, although to a lesser degree.

11. In the lumbar region, flexion, extension, and lateral flexion occur, but rotation is limited because of the inwardly facing articular facets. An understanding of the threecolumn concept of spine stability/instability is helpful to ensure that the proper orthosis is prescribed: The anterior column consists of the anterior longitudinal ligament, annulus fibrosus, and the anterior half of the vertebral body. The middle column consists of the posterior longitudinal ligament, annulus fibrosus and the posterior half of the vertebral body.

12. The posterior column consists of the interspinous and supraspinous ligaments, the facet joints, lamina, pedicles, and the spinous processes. The loss of normal spinal anatomy can affect the stability of the spine. Spine motion can be classified with reference to horizontal(transverse), frontal(coronal), and sagittal planes. the Spinal motion can shift the center of gravity, which is normally located approximately 2 to 3 cm anterior to the S1 vertebral body. White and Panjabi provided a summary of the current literature, revealing motion in flexion and extension, laterally, and axially.

13. In the cervical spine, extension occurs predominantly at the occipital C1 junction. Lateral bending occurs mainly at the C3-C4 and C4-C5 levels. Axial rotation occurs mostly at the CI-C2 levels. In the thoracic spine, flexion and extension occur primarily at the T11- T12 and T12 - L1 levels. Lateral bending is fairly evenly distributed throughout the thoracic levels. Axial rotation occurs mostly at the T1- T2 level, with a gradual decrease toward the lumbar spine.

14. The thoracic spine is the least mobile because of the restrictive nature of the rib cage. In the lumbar spinal segment, movement in the sagittal plane occurs more at the distal segment, with lateral bending predominantly at the L3-L4 level. Knowledge of the normal spinal range of motion helps in understanding how the various cervical orthoses can limit that range .

15. Soft collars provide very little restriction in any plane. The Philadelphia-type collar mostly limits flexion and extension. The four-poster brace and Yale orthosis have better restriction, especially with flexion-extension and rotation. The halo brace and Minerva body jacket have the most restriction in all planes of motion.

16. An interesting phenomenon related to movement in the spine occurs during motion. If the movement along one axis is consistently associated with movement around another axis, coupling is occurring. For example, if a patient performs left lateral movement (frontal plane) motion, the middle and lower cervical and upper thoracic spine rotate to the left in the axial plane . This causes the spinous processes (posterior side of the body) to move to the right.

17. In the lower thoracic spinal segment, left lateral movement in the frontal plane can cause rotation in the axial plane, with the spinal processes moving in either direction . The lumbar area has a contradictory movement pattern when compared with the cervical spine. With left lateral bending of the lumbar spine, the spinous processes move to the left. Patients with scoliosis and patients who undergo radiologic testing would benefit from an evaluation for the normal coupling patterns noted.

18. Nachemson performed the classic studies on normal adults that measured intradiskal pressures during a variety of activities and positions. Standing pressure was referenced as 100 in the lumbar disk. Lowest pressure measurements were noted in the supine position, with progressively higher pressures in the following positions: side lying, standing, sitting, standing with hip flexion, sitting with forward flexion, standing with forward flexion, and lifting a load while sitting with forward flexion

19. Description of Orthoses Head Cervicothoracic Orthoses

20. The halo orthosis provides flexion, extension, and rotational control of the cervical region. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the cervical spine.

21. This orthosis provides maximum restriction in motion of all the cervical orthoses. It is the most stable orthosis, especially in the superior cervical spine segment. A halo is used for approximately 3 months (10 to 12 weeks) to ensure healing of a fracture or of a spinal fusion. Usually a cervical collar is indicated after the halo is removed, because the muscles and ligaments supporting the head become weak after disuse. All pins on the halo ring should be checked to ensure tightness 24 to 48 hours after application.

22. Indications unstable cervical fractures postoperative management Contraindications stable fractures less invasive management could be used extremely soft skull might not tolerate the pin placement Special Considerations Skull density determines halo pin placement as well as the number of halo pins to be used. While four pins are used on average, more can be necessary in soft skulls (osteoporotic, fractured, or in an infant).

23. Cervical Orthoses Philadelphia or Miami provide some control of flexion, extension, and lateral bending, and minimal rotational control of the cervical region.

24. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the cervical spine. Circumferential pressure is also intended to provide warmth and as a kinesthetic reminder for the patient. Design and Fabrication: These orthoses are prefabricated, consisting of one or two pieces that are usually attached with Velcro straps.

25. The posterior aspect of the collar supports the head at the occipital level. Two-piece designs have an anterior and posterior section. The anterior section supports the mandible and rests on the superior edge of the sternum. Indications cervical sprains, strains, or stable fractures protection and to limit mobility after surgery to allow healing Contraindications These orthoses are not indicated for unstable fractures

26. Cervicothoracic Orthoses

27. Sternal Occipital Mandibular Immobilizer (SOMI) Biomechanics: provides control of flexion, extension, lateral bending, and rotation of the cervical spine. Pressure systems are used for control of motion, as well as to provide slight distraction for immobilization of the spine. A benefit of the SOMI orthosis is that it can be donned while the patient is in the supine position.

28. The SOMI is a good choice for patients who are restricted to bed, because there are no posterior rods to interfere with comfort of the patient. A headband can be added so that the chin piece can be removed. This maintains stability but improves accessibility for daily hygiene and eating.

29. Design and Fabrication: The SOMI is prefabricated, consisting of a cervical portion with removable chin piece and bars that curve over the shoulders. Also used are posts that fixate the cervical portion to the sternal portion of the orthosis. The anterior section supports the mandible and rests on the superior edge of the sternum, with the inferior anterior edge terminating at the level of the xiphoid. The posterior aspect of the orthosis supports the head at the occipital level.

30. Indications cervical sprains, strains, stable fractures protection and to limit mobility during the healing process in the postoperative patient Contraindications unstable fractures with ligament instability

31. Yale The Yale orthosis consists of chin and occipital pieces that extend higher on the skull in the posterior region; this increases comfort. The Yale orthosis is a modified Philadelphia collar with a thoracic extension. The extension consists of fiberglass that extends both anteriorly and posteriorly, and has thoracic straps that hold the sections together. The thoracic extension to the orthosis helps to stabilize injuries at the vertebral levels of C6-T2

32. Four-Poster The four-poster is a rigid cervical orthosis with anterior and posterior sections consisting of pads that lie on the chest and are connected by leather straps.

33. The struts on the anterior and posterior sections are adjustable in height. Also note that some cervical orthoses can also incorporate a sternal extension addition, which converts them from a cervical orthosis to a cervicothoracic orthosis (Aspen).

34. Cervico thoracolumbosacral Orthoses

35. Milwaukee Orthosis Biomechanics: for scoliosis management and provides control of flexion, extension, and lateral bending of the cervical, thoracic, and lumber spine.

36. The Milwaukee is a good choice for patients who need correction in the higher thoracic region of the spine. Indications scoliotic management of the high thoracic curves Contraindications lower thoracic and lumbar curves

37. Thoracolumbosacral Orthoses

38. Prefabricated Biomechanics: provides control of flexion, extension, lateral bending, and rotation using three-point pressure systems and circumferential compression. Design and Fabrication: designed in modular forms, with anterior and posterior sections connected by padded lateral panels and fastened with Velcro straps or pulley systems. Many of these are covered in breathable fabric and have a variety of different shapes and options, such as sternal pads or shoulder straps.

39. Indications traumatic or pathologic spinal fractures in the mid to lower thoracic region or lumbar region Contraindications obessity , excessive lordosis or a need for increased lateral stability

40. Custom-Fabricated Body Jacket Biomechanics: provides control of flexion, extension, lateral bending, and rotation. It uses three-point pressure systems and circumferential compression. It is molded to fit the patient and designed for patient needs. Anterior trim lines are usually located inferior to the sternal notch and superior to the pubic symphysis.

41. The posterior trim lines have a superior border at the spine of the scapula, and an inferior border at the level of the coccyx. These trim lines are adjusted during fitting to allow patients to sit comfortably and to use their arms as much as possible without compromising the function of the orthosis.

42. Indications traumatic or pathologic spinal fractures in the mid to lower thoracic region or lumbar region postsurgical management of fractures, after surgical correction spondylolisthesis, scoliosis, spinal stenosis, herniated disks, and disk infections Contraindications application of the orthosis over a chest tube, colostomy, or large dressings

43. Cruciform Anterior Spinal Hyperextension(CASH) Biomechanics: flexion control for the lower thoracic and lumbar regions.

44. The system consists of posteriorly directed forces through a sternal and suprapubic pad, and an anteriorly directed force applied through a thoracolumbar pad attached to a strap that extends to the horizontal anterior bar. When properly fitted, the sternal pad is one-half inch below the sternal notch, and the suprapubic pad is one-half inch above the symphysis pubis.

45. Indications mild compression fracture of the lower thoracic and thoracolumbar regions Contraindications unstable fractures or burst fractures Special Considerations Excessive pressure on the sternum can result in poor compliance with wearing schedule. Subclavicular pads may be added to help distribute this pressure.

46. Jewett Hyperextension Thoracolumbosacral Orthosis Biomechanics: provides flexion control for the lower thoracic and lumbar regions

47. This is done with a three-point pressure system consisting of posteriorly directed forces through a sternal and suprapubic pad, and an anteriorly directed force applied through a thoracolumbar pad attached to a strap that extends to the lateral uprights. A thoracolumbar pad is attached to a strap that extends to the lateral uprights and adjusts the tension on the body. When properly fit, the sternal pad will be one-half inch below the sternal notch, and the suprapubic pad will be one-half inch above the symphysis pubis.

48. Indications compression fractures of the lower thoracic and thoracolumbar regions and more lateral support than the CASH Contraindications unstable fractures or burst fractures Special Considerations Excessive pressure on the sternum might result in poor compliance with wearing schedule. Subclavicular pads can be added to help distribute this pressure

49. Taylor and Knight-Taylor Biomechanics: control of flexion, extension, and a minimal axial rotation via the three-point pressure systems for each direction of motion. For example, flexion is controlled by: the posteriorly directed forces applied through the axillary straps and the abdominal apron, and an anteriorly directed force through the paraspinal uprights.

50. Design and Fabrication: posterior pelvic band extending past the midsagittal plane and across the sacral area. Two paraspinal uprights extend to the spine of the scapula. An apron front extends from the xiphoid to just above the pubic area. Knight-Taylor has an additional thoracic band that extends from the uprights just below the inferior angle of the scapula to the midsagittal plane, and a lateral upright on each side that connects the pelvic band and the thoracic band. These bands provide additional lateral support and motion control to the trunk.

51. Indications postsurgical support (for years) of traumatic fractures, spondylolisthesis, scoliosis, spinal stenosis, herniated disks, and disk infections However, clinicians typically now prefer the custom-molded TLSO body jackets, because better control of position is obtained Contraindications unstable fractures that require maximum stabilization Special Considerations Pressure per square inch is higher because of the width of the bands and uprights

52. Lumbosacral Orthoses

53. Lumbosacral Corset Biomechanics: anterior and lateral trunk containment, and assists in the elevation of intraabdominal pressure. Restriction of flexion and extension can be achieved with the addition of steel stays posteriorly.

54. Design and Fabrication: made from cloth that wraps around the torso and hips. Adjustments are done with laces on the sides, back, or front. Closure can be with hook and loop (Velcro) or hook and eye fasteners or snaps. Many different styles are available in prefabricated sizes, usually in 2inch increments, and are designed to fit the body circumference at the level of the hips.

55. Indications low back pain, herniated disks and lumbar muscle strain, and to control gross trunk motion for pain control after single-column compression fractures with one-third or less anterior height loss Contraindications unstable fractures Special Considerations Long-term use can cause an increase in motion in the segments above or below the area controlled by the orthosis Muscle atrophy can also potentially occur after long-term use, causing an increased risk of reinjury. Patients can also develop a psychologic dependence on the support after injury

56. Lumbosacral Chair-Back Orthoses Biomechanics: limitation of flexion, extension, and lateral flexion. It also provides elevation of intraabdominal pressure.

57. Design and Fabrication: This orthosis has a pelvic band that lies posteriorly and extends laterally to just anterior to the midsagittal line. Laterally the ends fall midway between the iliac crest and the greater trochanter. The superior edge of the thoracic band is at the level of T9-T10 no or just distal to the inferior angle of the scapulae. The pelvic and thoracic bands are connected by two paraspinal uprights posteriorly and a lateral upright on each side at the midsagittal line. Orthoses can be fabricated from a traditional aluminum frame covered in leather, or thermoplastic material molded into the same shape.

58. Indications degenerative disk disease, herniated disk, spondylolisthesis, and mechanical low back pain, and for postsurgical supports for lumbar laminectomies, fusions, or diskectomies Contraindications unstable fractures, or conditions in the upper lumbar or thoracic area Special Considerations Adequate clearance of the paraspinal uprights is required to allow for some reduction of lumbar lordosis when the anterior apron is tightened and while sitting. Clearance on the lateral uprights over the iliac crests is also an area to be monitored

59. Sacroiliac Orthoses

60. Sacroiliac Orthosis or Sacral Orthosis Biomechanics: provides anterior and lateral trunk containment, and assists in the restriction of some pelvic flexion and extension. It also aids in compression of the pelvis. Design and Fabrication: This orthosis is usually made from cloth that wraps around the pelvis and hips.

61. Some models also include laces on the side in which adjustments can be made, whereas others use straps for adjusting. Indications pelvic fractures or symphysis pubis fractures or strains. It is useful to control motion and for pain control Contraindications unstable fractures, as well as fractures or conditions in the lumbar region

62. Scoliosis

63. Idiopathic (infantile, juvenile, adolescent) Congenital neuromuscular scoliosis have different etiologies, treatment approaches, and outcomes. 1- Idiopathic scoliosis is the most common form 2- Idiopathic infantile scoliosis is typically described from birth to 3 years of age 3- juvenile is from 4 years until the onset of puberty 4- adolescent type from puberty to closure of the facets

64. With idiopathic scoliosis the evaluation should reveal no anomalous vertebrae, spinal tumors, or other neurologic abnormalities. Most cases remain stable for a long period and progress late in life when osteoporosis and degenerative spinal conditions normally have their onset.

65. Progressive curves need to be treated, but there is not adequate evidence that scoliosis can be treated by electrical stimulation, nutritional supplementation, exercise, or chiropractic treatment. There is evidence to indicate that an orthosis can slow the progression of idiopathic scoliosis, and it is therefore the nonoperative treatment of choice. Juvenile idiopathic scoliosis is more likely to be associated with adult corpulmonal and death.

66. Treatment should begin when curves reach approximately 25 degrees. Because thoracic curves predominate, the Milwaukee brace might be more effective than the TLSO. Adolescent idiopathic scoliosis is the most common type for which an orthosis is indicated, usually for curves between 25 and 45 degrees. Curves with an apex at T9 or lower can be managed with a TLSO. Curves with a higher apex require a Milwaukee brace. Single lumbar curves are treated with a lumbosacral orthosis.

67. Congenital scoliosis is secondary to a vertebral anomaly that is present at birth: 1- Failure of part of the vertebrae to form ( hemivertebrae) 2- failure of the vertebrae to properly segment (block vertebrae) 3- combination of both Congenital scoliosis is associated with abnormal development in the embryo, and associated developmental abnormalities in other organ systems should be considered, especially in the renal, urinary, and cardiac systems.

68. Neuromuscular diseases Neuromuscular diseases are also associated with scoliosis.The prevalence of scoliosis in this population is much higher than with idiopathic scoliosis, from 25% to 100%. In pediatric patients with a spinal cord injury, almost 100% have scoliosis. In general, there is a significant chance of progression in the presence of severe neurologic disease. In adults scoliosis curvatures tend to be relatively benign and of the C-type appearance, and are less likely to progress to the extent that they cause clinical cardiopulmonary problems.

69. Progression of the curve can occur in adulthood, which is typical for scoliosis in general. Spasticity or flaccidity can be present, depending on whether there is upper versus lower motor neuron involvement. Multisystem involvement is more common in this group because these diseases are not isolated to the spinal column. Consideration should also be made for the presence of contractures, hip dislocations, sensory abnormalities, mental retardation, and pressure ulcers.

70. Scoliosis can continue to progress despite the proper use of an orthosis, and in these cases appropriate surgical referrals should be made. An important factor to consider before surgery is the pulmonary function in a patient with neuromuscular disease. Before surgery is considered, the forced vital capacity and forced expiratory volume in 1 second should be at least 40% of that predicted for the patient's age. Fusions are delayed as long as possible in an attempt to achieve maximal spinal growth (>10 years of age). Declining pulmonary function is a consideration for performing surgery earlier.

71. Duval- Beaupere followed the long-term progression of idiopathic scoliosis and noted that curve progression accelerated during growth spurts. Curves measured from 5 to 29 degrees, and the curves from 20 to 29 degrees progressed in almost 100% of the patients. Approximately 50% of the curves from 5 to 19 degrees appeared to progress. Curve progression has been explained using Euler's theory of elastic buckling of a slender column. Axial compressive forces evidently cause a column to buckle. This is associated with height growth and weight gain, especially increased upper limb weight during growth spurts.

72. An increase in height and weight commonly occur together and might synergistically promote curve progression. The timing for surgery in a child with scoliosis is controversial: 1- A child with a curve greater than 45 degrees 2- A child who is still growing 3- child who cannot or does not wear a brace are at a greater risk of curve progression and may be considered for surgery

73. Thoracolumbosacral Low-Profile

74. Scoliosis Orthoses Boston Brace, Miami Orthosis, Wilmington Brace Biomechanics: provide dynamic action using three principles (endpoint control, transverse loading, and curve correction) to prevent curve progression and to stabilize the spine.

75. Wilmington Boston

76. The effective nonoperative treatment of idiopathic scoliosis using a low-profile TLSO has been demonstrated over the past 30 years. The most common of these orthoses is the Boston brace, introduced by Hall and Miller in 1975. This system is available in prefabricated modules that are available in 30 sizes and can be ordered by measurement; they are then custom-fit to the patient. Modules can be used to fit approximately 85% of patients. Six of these sizes will fit approximately 60% of patients requiring an orthosis. The orthosis can also be custom-fabricated from a mold of the patient's body.

77. Indications immature skeleton and documented progression of a thoracic or thoracolumbar idiopathic scoliosis that measures 25 to 35 degrees (measured by the Cobb method) and has an apex of T7 or lower Contraindications curves that measure greater than 40 degrees in who are skeletally immature curves in excess of 50 degrees after the end of growth Both of these types of patients are typically candidates for surgery

78. Special Considerations The effectiveness of any orthotic system depends on compliance with the wearing schedule. Most patients should wear the orthosis 23 to 24 hours per day for it to be effective. Some physicians allow time out of the orthosis to participate in athletic activities or swimming and some special occasions, and this seems to improve acceptance and compliance.

79. Future Technology

80. Computer-Aided Design and Computer-Aided Manufacturing Technology is available to help the practitioner improve efficiency in design and fabrication, as well as reducing the invasiveness of orthotic measurement of the patients. The development of computer-aided design (CAD) and computeraided manufacturing (CAM) has allowed the fabrication of orthoses today in less time than it took only a few years ago. The Bio Scanner is one of the CAD-CAM systems available.

81. It combines CAD, laser scanning, threedimensional imagery, and motion-tracking technology to design orthotic and prosthetic devices. The body part involved is scanned via a handheld scanning wand, which uses a motion-tracking device embedded in the scanner. The wand is passed over the body part. A three-dimensional image of the body part is transmitted to the computer, and the software interprets the data. Any portion of the body can be directly scanned. There is no size limitation. A miniature transmitter is placed on the body to accommodate for any movement.

82. The BioScanner is able to image negative and positive models, allowing the clinician to use the clinical techniques required for each patient. With scan-through-glass technology that the company provides for use with its scanner, the clinician can position the body horizontally for a TLSO. The precision of the Bio Scanner captures shapes to an accuracy of 0.178 mm. Patients can be scanned for spinal jackets without movement from supine to prone positions. An option in the computer software allows one hemisphere to be scanned, and then the computer develops the other hemisphere to form a complete image.

83. Bone Stimulation The CMF Spinalogic bone growth stimulator is a portable, batterypowered, microcontrolled, noninvasive bone growth stimulator indicated for adjunct electromagnetic treatment to primary lumbar spinal fusion surgery for one or two levels.

84. There are different bone stimulators on the market that are in use today. Some are used in conjunction with spinal orthoses and do not interfere with the control that the orthosis provides or the treatment protocol set by the physician. Some of the benefits of these bone stimulators are as follows: (1) lightweight, comfortable, and easy to use (2) after an anterior or posterior approach in surgery (3) noninvasive This treatment has been shown to give a 21% point increase in healing over those who did not use the stimulator. It also helps the body's own healing process to begin working.

85. shahramironhide@yahoo.com