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SPINAL ORTHOTICS Paul S. Jones, DOHarry S Truman VA2018

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Terminology Orthosis: A singular device used to aid or align a weakened body partOrthoses: Two or more devices used to aid or align a weakened body partOrthotics: The field of study of orthoses and their managementOrthotic: An adjective used to describe a deviceOrthotist: A person trained in the proper fit and fabrication of orthoses

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Prescription: Prescriptions should include the following items:Patient’s name, age, and gender, Current dateDiagnosisFunctional Goal,Orthotic descriptionArea coveredFlexible or Rigid deviceCustom or Off-the-shelfControl desired based upon biomechanics of the spineRestriction of sagittal plane motionRestriction of coronal plane motionRestriction of transverse plane motionPrecautionsPhysician name and unique physician identifier numberPhysician signature, office address, contact phone number.

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Objective of Spinal Orthoses Control of Painlimiting motion or weight bearingProvides heat to an areaProtection against further injuryLimits motionPromotion of healing of fracturesStabilization of vertebral segmentProvides stabilization when soft tissue cannotAssistance for muscle weaknessServes as a kinesthetic reminder

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Purpose of Spinal Orthoses Prevention and Correction of DeformitiesBy providing external forcesApplying corrective forces to abnormal curvatures3-point pressure systemReduction of Axial LoadingMorris,1961 JBJSElevated intra-abdominal pressureReduces the net force applied to spine during the act of lifting a weight from the floorReduces intradiscal pressure approximately 30% in lumbar spinePostsurgical StabilizationWith or without fracture John Redford ,PM&R secrets Chapter 96

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Ideal Orthosis FunctionalFits wellLight in weightEasy to useCosmetically acceptableEasily maintained/repairedIdeally locally manufactured Different than the “3H’s”predicing failure Hot, heavy, horrible looking

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Prescription Spinal Orthotics Diagnosis/IndicationsGoals of the orthotic deviceArea to be coveredControl desiredBased upon biomechanics of the spineRestriction of sagittal plane motionRestriction of coronal plane motionRestriction of transverse plane motionFlexible Device vs RigidCustom vs Off-the-shelf Tenet of Orthotic classical practice“Customized orthoses more effectively limit or control motion better than prefabricated or off-the-shelf orthoses”

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Custom vs Off-the-shelf Tenet of Orthotic classical practice“Customized orthoses more effectively limit or control motion better than prefabricated or off-the-shelf orthoses”More intimate fit with customBetter control of Triplanar Motion with customBetter control of lateral flexion and Rotation with custom Unequal panels from OTS that creates flexion or extension componentsRotation not controlled in OTS due to not locking down on ASIS or the rib cageCustom better adjustment for pendulous abdomenCustom more comfortable to wear than OTSBernardoni: Comparison between custom and noncustom spinal orthoses: PM&R Clinic NA 12(2006)73-89

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Nomenclature/Categories Name by the body regions that they cross/ EponymsCO: Cervical OrthosisSoft or rigid (Philadelphia, Aspen, Miami, Newport)CTO: Cervicothoracic orthosisHalo, SOMI, MinervaCTLSO: Cervicothoracolumbosacral orthosisMilwaukee TLSO: Thoracolumbosacral orthosisCustom-molded body jacket, CASH, JewettLSO: Lumbosacral orthosisChairback, Knight, corsets/bindersSO: Sacral orthosisTrochanteric belt, sacral belt, sacral corset RigidityRigidSemirigidFlexible

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Types HaloSOMICervical Collar (Miami-J)CTOTLSO with proximal extensionTLSOTLSO with leg extensionChairback cervical thoracal lumbar

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Need to understand Spinal Motion

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Vertebral Motion-Cervical Atypical Cervical VertebraeAtlas (C1) and Axis (C2)Provides 50% of flexion/extension and rotation of cervical spineTypical Cervical VertebraeC3-C7Provides 50% of flexion/extension and rotation of cervical spineMaximum flexion/extension C5-6

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Vertebral Motion-Thoracic Thoracic spineAll limited by facets and ribs all direct/ Mostly Rotation Upper (T1-4)Rotation> flexion/extension>sidebendingMiddle (T5-8)Rotation> flexion/extension>sidebendingLower (T9-11)Flexion/extension>sidebending>rotation

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Lumbar Vertebral Motion Lumbar spine Major motion is flexion/extensionSmall degree of sidebending and very little rotationThoracolumbar Junction (T12-L1)Most mobile section of the spineMidlumbar (L2-4)Lumbosacral Junction (L5-S1)Area more difficult to control

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Range of Motion Spinal Area Braddom 3rd edition

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Soft Cervical Collar Foam RubberBenefitWarmthPsychological ReassuranceKinesthetic reminder to limit motionNo structural supportMay not reduce duration of intensity of pain Flexion/Ext limited 5-15% Lateral Bending limited 5-10% Rotation limited 10-17%

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Miami J Collar PolyethyleneHas tracheostomy openingCustom adjustment around chin and occiputLowest level of mandibular and occipital tissue-interface pressure compared to other rigid CO’sLower skin temperatureLess sweatingLess skin breakdownIndicationss/p Anterior Cervical fusionJefferson’s Fx (C1)Hangman’s fractureTraumatic spondylolisthesis of C2 on C3Dens type I fractureAnterior diskectomyCervical trauma in unconscious patientsCervical Strain Flexion/Ext limited 55-75% Lateral Bending limited 60% Rotation limited 70%

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Malibu Collar 2-piece orthosisAnterior opening for tracheostomyAdjustable chin supportIndicationss/p Anterior Cervical fusionDens type I fractureAnterior diskectomyCervical trauma in unconscious patientsCervical Strain Flexion/Ext limited 55-60% Lateral Bending limited 60% Rotation limited 60%

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Use of CO for Axial Neck Pain No evidence for rigid or soft COOnly thing beneficial is therapeutic exerciseIn “whiplash” injury could prolong return to work34 days vs. 17 days (p<0.05) Crawford, Early Management and outcome following soft tissue injury of the neck: A random controlled trial Injury: 2004;35 (9) 891-895

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Philadelphia Collar with Thoracic Extension 2-piece Plastizote FoamHigh capillary closing pressureIncrease skin tempIncrease sweatingIncrease risk of ulcerIndicationss/p Anterior Cervical fusionDens type I fractureAnterior diskectomyCervical trauma in unconscious patientsCervical Strain Flexion/Ext limited 65-70% Lateral Bending limited 30-35% Rotation limited 60-65% Thoracic support adds restricted motion C6-T2Some say to T5

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Sternal-occipital-mandibular Orthosis (SOMI) 3-Poster CTOAnt chest plate to xiphoid processRemovable chin strapControl of MotionFlexionC1-3ExtensionLess control than other CO’sIndicationsAA instability-RANeural arch fx C2Due to flexion instability Flexion/Ext limited 70-75% Lateral Bending limited 35% Rotation limited 60-65%

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CTO CTOs provide significantly more restriction of intervertebral flexion and extension than CO’sControls motion down to around T5

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Halo Device 4-Poster ControlControls down to T3Usually worn 8-12 weeksGood control Occiput to C1Poor control mid-cervical region Flexion/Ext limited 65-70% Lateral Bending limited 30-35% Rotation limited 60-65%

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Halo Device Positioning Anteriorly1cm above orbital rim lateral orbitPosteriorly1 cm above the top of the ear/below largest diameter of skull

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Halo Device ProblemIntersegmental “snaking”Flexion of one vertebral segment with extension of the adjacent vertebral body Koch + Nichel:31% of normal motion at lower cervical level (C4-5)Lind: 2-17° C2-C6Most OA PrecautionsAvoid Shoulder Abduction <90°Avoid Shoulder ShruggingDistraction forcesDO NOT!!!!Lift, turn, move patient by pulling on vest/rods or superstructure

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Halo Device Pin Care Every 8 hours in hospitalBid after discharge others qdCheck for crusting,drainage,redness, swellingPin Cleaning dailySterile Q-tipAntimicrobial soap and Normal salineNot Betadine, Hydrogen peroxide, or alcoholPin corrosionDisruption of Healing When placedCheck Lateral X-ray alignmentHorizontal positionBed elevated 45 degreeBed elevated 90 degree Sandra Mangum RN, A comprehensive guide to the halo brace-application,care, patient teaching AORN J Sept 1993,Vol 58,#3

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Halo Device Complication Pin looseningClicking/grating/creaking soundSensation of loosenessPain in pin siteHeadacheHalo vest movementTorque Wrench settingAdult8 inch-poundChildren2-5 inch-poundCheck pin once a month Signs of Brain AbscessPsychosisScalp pin cellulitisHeadacheEye painFeverSeizure

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Minerva Body Jacket Lighter than haloNo pinsNo risk of infection or slippageLess restriction than Halo for OABetter control intersegmental than HaloIndicationUnstable cervical spineCompliant patientPatient with skull FxPreschool childrenDecrease weightIncrease comfort

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Alterative to Halo/Minerva Lerman noninvasive halo systemUse in children

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Braddom 3rd edition

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Efficacy of Cervical Orthoses Agabegi: Spinal Orthoses JAAOS, November 2010, Vol 18,#11

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Summary Best CO All orthoses tend to control flexion better than extensionIncreasing height of the rigid collar more restricted motionMay also lead to increase cervical extension (?undesirable) The halo is the most effective orthosis for use in controlling flexion and extension at C1-C3, followed by the 4-poster brace and then the CTOs CTOs are best for use in controlling flexion and extension at C3-T1, whereas the SOMI is best for use in controlling flexion at C1-C5 The CTO brace is the second best orthosis for use in controlling rotation and lateral bending in the cervical spineThe SOMI controls extension less effectively than do other orthosesThe halo is the best orthosis for use in controlling rotation and lateral bending at C1-C3The 4-poster (Halo) brace is slightly better than the CTO brace for use in controlling lateral bending in the cervical spine

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Summary Best CO Miami J CollarLowest level of mandibular and occipital tissue-interface pressure compare to other CO’sCervical CollarsIncrease intracranial Pressure in TBISwallowing effectedNarrowing of PharynxExtension or Hyperextension of C-spineRigid COLess controlOcciput to C2C6-7Good controlMid cervical (better than Halo) Philadelphia CollarNot well ventilatedIncreased skin macerationIncreased pressure on chin, mandible, occiputIncreased risk of tissue ischemia and ulcer

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Thoracolumbar Orthosis(TLSO) 3-point pressure systemSupplies anterior abdominal pressureIncrease intracavity pressureDecrease lumbar lordosisDecrease load on the vertebra and discRestricts trunk and intervertebral motionControl of motion categoriesFlexionFlexion-extensionFlexion-extension-lateral bendingFlexion-extension-lateral bending-rotationSupports/aligns spineMost restricted motion cephalad regionLeast control at L/S junction

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Usual Indications and Studies for TLSO’s From Michael Zlowodzki MD,University of MinnesotaDepartment of Orthopaedic Surgery-Spinal Orthotics Lecture

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T10-L2 Burst fracture Treatment Non-Operative group (n=23): Significantly less disabilitySignificantly lower pain scoresSignificantly higher physical functioning scoresLower cost ($11k vs. $49k)Complications more frequent in Op groupAll patients remained neurologically intactBraces/Casts avoid surgical complicationsOperative Compared with Nonoperative Treatment of Thoracolumbar Burst Fracture without Neurologic Deficit: A Prospective, Randomized Study. Wood et al. JBJS Am 2003

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T/L Burst Fractures without Neurological Deficit: RCT Op vs. Brace N=80Op: Posterior 3-level fixation earlier pain relief and partial kyphosis correction (gradually lost)Earlier pain reliefNon-op: Hyperextension braceFUNCTIONAL OUTCOME AT 2 YEARS SIMILARSafe treating burst fx with TLSO*Li-Yang Dai: Conservative Treatment of Thoracolumbar Burst Fracture: Spine Vol 33, No 23 pg 2536-2544 2008* Nonoperative Treatment vs. Posterior Fixation for Thoracolumbar Junction Burst Fractures without Neurological Deficit. Shen et al. Spine 2001

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Compression Fractures (<30%): Bracing vs. No external support T12-L5; Mostly L1One-column fractures of the thoracolumbar spine with <30% compression can be treated with early ambulation and hyperextension exercises Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000

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Flexion Control

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Cruciform Anterior Spinal Hyperextension Brace (CASH) Flexion controlDoes not limit lateral bending or rotationEasy to donn/doffIndicationsThoracic/lumbar vertebral body FxKyphosis reduction/osteoporosisContraindicationUnstable FractureWhere extension is prohibitedCan cause excessive hyperextension forces of the posterior elements Flexion/Extension limit T6-L1

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Jewett Hyperextension Brace Flexion controlDoes not limit lateral bending or rotationIndications(T6-L1)Thoracic/lumbar vertebral body FxKyphosis reduction/osteoporosisPost op stabilization of TL FxContraindicationUnstable Fracture3-column fracturesCompression Fx above T6Increased motion above padWhere extension is prohibitedCan cause excessive hyperextension forces of the posterior elements Flexion/Extension limit T6-L1

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Flexion-Extension Control

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Taylor Brace Limited motion of Mid to lower thoracic to upper lumbar regionIncrease motion Upper thoracic and lower lumbar & LS junction

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Flexion-Extension-lateral Control

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Knight-Taylor TLSO Limits flexion,extension and lateral bendingPoor rotary controlMore of scapular band than TaylorIndicationThoracic and lumbar compression FxPost-op and nonsurgical management of stable thoracic or lumbar fx’sArthritisSpinal weakness

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Flexion-Extension-Lateral-Rotary Control

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Custom-Molded Body Jacket Polypropylene or PlasticBest control all planesIncreases intracavity pressureDiffuse distribution of pressuresIdeal for Neurologic InjuriesReduces myoelectric activity of erector spinae musclesT3-L3 areasAnterior shell½ inch above pubic symphysis to sternal notchPosterior shellSpine of scapula to sacrococygeal junction

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Lumbosacral Orthoses (LSO)Flexible or Rigid Elevated intra-abdominal pressure reduces net force applied spine during the act of lifting a weight from floorMorris: JBJS, 1961;43:327-351Tight brace can reduce intradiscal Pressure in lumbar spine by ≈30%Nachemson, JBJS,1964;46:1077-1092Variable Effect on myoelectric activity of abdominal muscles/Extensors of spineLantz,Spine Vol(11),No 8 1986 838-842No benefit for Low back painConsensus statement APTA Guidelines LBP 2012

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Flexible LSO Corsets or bindersIndicationsPain reliefPostural supportVasomotor supportSCIRespiratory SupportSCI

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Flexion-Extension Control Sagittal Plane Limits Flexion-ExtensionL1-L4Minimal limitation of rotationLateral bending by 45%Unloads intervertebral disc Chairback

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Chairback LSO Sagittal Plane Paraspinal barsButterfly pelvic bandSacrococcygeal junctionThoracic bandBelow inferior angle of scapulaAbdominal supportTightening the abdominal support creates intra-abdominal pressure, which effectively reduces lordosis in the lumbar spineIndicationsLower back weakness or painSacroiliac painArthritiss/p Lumbar laminectomy

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Extension-Lateral Control

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Williams Flexion LSO Sagittal and Coronal Plane Control ComponentsPelvic bandThoracic bandLateral uprightsPivotable attachmentsNo posterior uprightIndications:Creates Lumbosacral flexionIncludes extensor activity of hip and spineRelieves postural imbalance in low back pathologies with lordosis Spondylolysis Spondylolisthesis

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Williams Flexion LSO Sagittal and Coronal Plane Control Tightening the abdominal support creates intra-abdominal pressure increases lumbosacral flexion

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Flexion-Extension-Lateral Control

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Knight LSO Sagittal and Coronal Plane Control ComponentsParaspinal barsLateral uprightsPelvic bandThoracic bandAbdominal supportTightening the abdominal support creates intra-abdominal pressure which effectively reduces lordosis by distending the lumbar spine. Indications:Lower back weakness or pain,Arthritis,Need for immobilization of the lumbosacral region

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Custom-molded,plastic LSO

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Orthotic Treatment Compression Fracture Only 2 Orthotics scientifically studied for efficacy:Spinomed®-activates back muscles to straighten the dorsal spine and decrease kyphosis to treat chronic VCFs http://www.spsco.com/press/07-12-06c.html Pfeifer M, AJPMR 2004

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http://patimg1.uspto.gov/.piw?docid=US006063047&SectionNum=2&IDKey=DA2095C211DB&HomeUrl=http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO2%2526Sect2=HITOFF%2526p=1%2526u=%25252Fnetahtml%25252FPTO%25252Fsearch-bool.html%2526r=1%2526f=G%2526l=50%2526co1=AND%2526d=PTXT%2526s1=6,063,047%2526OS=6,063,047%2526RS=6,063,047 Spinomed Design

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Increased back weakness? Lantz and Schultz, Spine 1986Increase electrical activity of back muscles when LSO wornPrinciple effect may be a biofeedback mechanismPfeifer M, AJPMR 2004Females with one clinical vertebral fracture caused by osteoporosis and an angle of kyphosis of 60 degrees as measured by stereophotomorphometry. Noted: Significant increase in trunk muscle strengthIncrease muscular activity while wearing the LSO

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Spino-Med by Pfeifer Wearing the orthosis for 6-mo period, 2 hours per day 73% increase in back extensor strength 58% increase in abdominal flexor strength 11% decrease in angle of kyphosis 25% decrease in body sway 7% increase in vital capacity 38% decrease in average pain15% increase in well-being 27% decrease in limitations of daily living. Overall tolerability of the orthosis was good no side-effects were reported drop-out rate of 3% was rather low.

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Rucksack Orthosis for Osteoporosis (PTS) Characteristic postures arising from weakened back muscles and improved walking posture with rucksack spinal orthosis

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Postural Training Support(PTS) Encourages back extension through the addition of weightsLimits flexionPosterior pocket holds 2 lb weightAllows progressive build up of weightAdjustable straps to accommodate fittingSizing done by shoulder measurementWeights made of vinyl with steel fillersVelcro closure for easy donning/doffing

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Spinal Orthosis by Segment

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Scoliosis Orthoses TLSOs: Accommodative and Corrective

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Accommodative TLSO Fabricated of soft peliteReinforced with Kydex or rigid plasticAmbulatory and non-ambulatory patientsFixed alignments

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Accommodative TLSO Maintain head and trunk over pelvisLevel shouldersReduce or minimize shear forcesAllows patient to increase upper extremity use or decrease dependence

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Accommodative TLSO Key to good positioning!Enhances mobility baseAssists patients with pulmonary compromiseUsed with fixed position wheelchair, tilt in space, or molded seats

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Idiopathic Scoliosis Milwaukee-style CTLSO

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Biomechanic in Scoliosis Large curves are more readily straightened by elongationSmaller curves are more readily straightened by application of lateral forcesUsually placing pad below the apex causing lifting forceSupine more effective force of TLSO than uprightKey to using bracing at nightElongation of curveReducing lumbar lordosis more effective in treating scoliosis in lumbar and thoracic spineReduction of the lumbar lordotic curve at the expense of flattening the thoracic kyphotic curve ( may be problem)Correct coronal plane motion but much less 3-D motion Watts, Bracing in Spinal Deformities 1979

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Corrective TLSO Progressive correction of idiopathic spinal curvaturesSupple curves (20°-40°)20°-30° observe initially, if curve progresses by 5° then brace30°-40° prompt use of orthosis40°-50° requires surgery, but orthoses may retard progression long enough to allow further trunk growth prior to fusionIndicated Risser <2Stabilization of congenital spinal curvaturesPrevention of progressionUsually same curve beginning and end of useMoe + Winter “purpose of bracing is to “keep small curves from getting bigger, not to make big curves smaller”Used full-time16-20 hrs/day until skeletal maturity-Optimum is 23 hrs/day

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Risser Sign: Apophysis closes from anterior to posterior

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Spinal Orthotics in Scoliosis Curves w/ apices T-8 or lower may be treated w/ underarm braces Wilmington brace (custom made) Boston brace (prefabricated) High thoracic curves may require the Milwaukee Brace “Metal vertical suprastructure with pelvic foundation” Boston Milwaukee Brace

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Charleston Brace Prescribed for part-time wear, usually 8 hours at nightIs designed to ‘unbend’ the scoliotic curveFew long-term follow-up studies

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Boston vs. Charleston Katz: 1996 compared the effectiveness of the TLSO Boston brace versus the TLSO Charleston braceBoth were statistically comparable in preventing curve progression and surgery in single curves of 25-35°Boston brace was more effective in treating curves 36-45 ° and multiple curvesWatts 1977Boston not use if apex above T10 or curves greater than 40°

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Scoliosis Orthoses

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Weaning from TLSO in Scoliosis Slow wean is the bestWant no loss of correction up to 3 degreesOff 2 h/day then Repeat X-ray 3 monthsOff 4 h/day then repeat X-ray 3 monthsOff 8 h/day then repeat X-ray 3 monthsOff 12h/day then repeat X-ray 3 monthsUse TSLO “night only” for minimum of 1 year Orthotics for Spinal Deformity, Robert Winter: Clinical Orthopaedics & Related Research No:102, July-August 1974 pg 72-91

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Bibliography Kulkarni, Shantanu: Spinal Orthotics,http://emedicine.medscape.com/article/314921, Aug 25, 2008Bernardoni: Comparison of Custom and noncustom Spinal Orthoses, Phys Med Rehabil Clin N Am ,17 (2006) 73–89Lantz SA, Schultz AB: Lumbar spine orthoses wearing: Effect on trunk muscle myoelectric activity. Spine 1986;11:838–4234. Pfeifer M, Begerow B, Minne HW: Effects of a new spinal orthosis on posture, trunk strength, and quality of life in women with postmenopausal osteoporosis: A randomized trial. Am J Phys Med Rehabil 2004;83:177–186.

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Bibliography Pomerantz,F: Chapter 62 Spinal Orthotic, Delisa Physical Medicine & Rehabilitation, Principles and Practice 4th ed, 2005 pg 1355-1365Cuccurulo: Physical Medicine and Rehabilitation Board Review: 2005Katz DE, Richards BS, et al. A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis. Spine 1997; 22:1302-1312.

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Bibliography Orthoses for Spinal Conditions-Clnical Decision Making, Chapter 17; Prosthetics and Orthotics, Seymore pg 427-447Bernardoni: Comparison between custom and noncustom spinal orthoses: PM&R Clinic NA 12(2006)73-89Li-Yang Dai: Conservative Treatment of Thoracolumbar Burst Fracture: Spine Vol 33, No 23 pg 2536-2544 2008

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Bibliography Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine? Ohana et al. J Spinal Disorders 2000H.G. Watts, Boston Brace system for the treatment of low thoracic and lumbar scoliosis by use of girdle without suprastructure; Clinical Orthopaedics and Related Research, No 126, July-August 1977Agabegi :Spinal Orthoses, J. Am Acad Orthop Surg, 2010;18:657-667Watts H.G, Bracing in spinal deformities. Orthop Clin North Am, 1979, Oct, 10(4):769-785