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The Use of Spinal Orthoses After Spinal Cord Injury David X

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The Use of Spinal Orthoses After Spinal Cord Injury David X. Cifu, M.D. The Herman J. Flax, M.D. Professor and Chairman Department of Physical Medicine and Rehabilitation – PowerPoint PPT presentation

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Title: The Use of Spinal Orthoses After Spinal Cord Injury David X


1
The Use of Spinal Orthoses After Spinal Cord
Injury
  • David X. Cifu, M.D.
  • The Herman J. Flax, M.D. Professor and Chairman
  • Department of Physical Medicine and
    Rehabilitation
  • Virginia Commonwealth University

2
SCI Rehabilitation Model Systems Project
  • 16 centers across the United States with uniform
    admission criteria and rehabilitation care
    protocols.
  • More than 20,000 subjects since mid-1970s.
  • This research supported by the National Institute
    on Disability and Rehabilitation Research, Office
    of Special Education and Rehabilitation and
    Rehabilitative Services, U.S. Department of
    Education Grant H133N50015

3
Spinal Cord Injury
  • SCI incidence in the United States is 30 to 40
    per million, or 7000-10,000 new cases annually.
  • While SCI occurs predominantly in individuals
    aged 16 to 30 ( 60), over the past quarter
    century the age at time of SCI has been rising .
  • Nearly 20 of new SCI injuries occur in those
    over 60 years

4
Spinal Cord Injury
  • Short term costs range from 100,000 - 1 million.
  • Lifetime medical costs exceed 1 million/person.
  • Significant burden on non-medical system (family,
    vocational, formal support systems)

5
Spinal Cord Injury
  • Extensive short and long-term medical issues
  • Neurogenic bowel and bladder
  • Cardiovascular
  • Pulmonary
  • Integument (Skin)
  • Osteoporosis
  • Pain

6
Spinal Orthoses History
  • Ancient Egyptians used first splints nearly 5,000
    years ago, but not to stabilize joints or body
    parts.
  • Middle Ages armorers manufactured splints that
    protected as well as stabilized the body.
  • French surgeon, Ambroise Pare developed metal
    corsets in the late 16th century

7
Spinal Orthoses History
  • Lorenz Heister is credited with developing the
    first spinal orthosis in the late 17th century.
    It was quite similar to the modern day Halo
    brace.
  • The basic principles of spinal immobilization
    have actually changed little in the past 300
    years, however the materials used and combination
    of surgery and bracing has changed tremendously.

8
Spinal Orthoses Principles
  • Four objectives of spinal orthoses
  • controlling spinal position by external forces
  • applying corrective forces to abnormal curvatures
  • providing spinal stabilization when soft tissues
    cannot
  • restricting spinal segment movement after trauma

9
Spinal Orthoses Principles
  • Orthoses work through the biomechanical effects
    of a three-point pressure system on
  • trunk and head support
  • motion control
  • spinal realignment
  • partial weight transfer of the head to the trunk
    when in upright

10
Spinal Orthoses Principles
  • Orthoses effectiveness is affected by
  • points of application
  • direction and magnitude of the forces applied
  • tightness of the device
  • type of trauma/injury and the instability
    produced
  • body habitus of the individual wearing it

11
Spinal Orthoses Principles
  • Spinal orthoses can also have significant
    negative effects
  • axial muscle atrophy secondary to reduced
    activity
  • immobilization can promote contractures
  • excess pressure, irritation, and moisture
    build-up can result in skin breakdown
  • psychological dependency can occur that increases
    physical dependence
  • significant functional limitations of orthoses
    can have untoward psychosocial and economic
    effects

12
Cervical Orthoses
  • To be effective they must control both gross and
    intersegmental movements of the head and neck.
  • C0-C1 segment involves significant
    flexion-extension, minor lateral bending and
    little rotation.
  • C1-C2 segment involves primarily rotation (50 of
    all rotation) with limited flexion-extension.
  • C3-C7 segments involve flexion extension (C5-C7),
    lateral bending (C2-C3), and rotation (C2-C3).

13
Cervical Orthoses
  • Challenges to immobilization
  • extremely mobile joint complex with multiple
    planes
  • little body surface available for contact
  • high incidence of skin breakdown (occiput, chin)
  • pressure-related pain common (clavicles, chin)
  • hygiene issues limit comfort (shaving)
  • Opportunities
  • strong interest in pre-hospital immobilization
    systems
  • 40-million/year market

14
Cervical Orthoses Collars
  • Cervical collars 25-100 normal motion
  • soft/foam - inexpensive and comfortable no
    immobilization provides warmth and psychological
    support primarily serves as a reminder 75-100
    normal motion
  • hard/rigid - mildly limits flexion/extension if
    optional occipital/mandibular struts in place no
    limitation of lateral bending or rotation
    painful at clavicles
  • Philadelphia - significantly limits
    flexion/extension primarily 25-30 normal motion
    uncomfortable at clavicles
  • Other - Jobst Vertebrace, Miami J, Aspen/Newport,
    NecLoc may be slightly superior to Philadelphia

15
Cervical Orthoses Posters
  • Poster Appliances 10-28 normal motion
  • Four poster - mandibular/occipital supports with
    struts to anterior/posterior thoracic plates
    excellent limitation of flexion/extension.
  • Guilford/Two Poster - similar to four poster with
    addition of axilla straps and thoracic belt.

16
Cervical Orthoses CTOs
  • Cervicothoracic Orthoses 10-25 normal motion
  • Yale - Combination of a high Philadelphia collar
    with thoracic jacket and axillary straps
    Excellent flexion/ extension control Fair
    rotation control
  • SubOccipital Mandibular Immobilizer (SOMI) -
    Similar to four poster with crisscrossing full
    thoracic body jacket removable head strap to
    allow mandibular support to be removed with
    eating may be applied w/o turning patient
    comfortable Fair restriction of
    flexion/extension only

17
Cervical Orthoses Halos and Beyond
  • Halo devices 10-25 normal motion
  • Halo Vest - metal/graphite ring attached to the
    skull in 4 points affixed to full thoracic vest
    by 4 posters Excellent control of all motions
  • Halo Cast - similar to vest except cast is
    fabricated to get improved purchase
  • Thermoplastic Minerva Body Jacket (TMBJ)
  • improvement over casted version (lighter) may be
    as effective as Halo vest non-invasive (no pins)

18
Cervical Orthoses Utility
  • Orthoses do not achieve total or near total
    immobility. Overall fit quite variable and will
    change with usage.
  • In the face of neurological deficit, non-surgical
    patients require 3 months orthosis.
  • When good anatomic alignment can be achieved,
    need for surgery is unclear.
  • Non-surgery patients have better long-term ROM.
  • Surgical patients require 6 weeks orthosis.

19
Cervical Orthoses Utility
  • Higher cervical injuries are better immobilized.
  • Individuals with injuries to the facet joints
    (dislocation /- fracture) are most likely to
    need surgery.
  • A patient who is unstable at 6 weeks
    (post-surgery) or 12 weeks (non-surgical) despite
    orthosis use will need later surgery (although
    instability is not necessary absolute
    indication).
  • Rapid mobilization achieved with either method.

20
ThoracoLumbar Orthoses
  • More commonly prescribed than cervical orthoses.
  • Similar immobilization issues as in cervical
    region. Sacrum is the foundation of the spine.
  • Actual control of motion poorly studied.
  • Extensive research on the usage of TLOs
    (variable types) in the prevention of injuries
    has not demonstrated any reduction in stresses to
    the spine, muscles, or abdominal contents with
    these devices.

21
ThoracoLumbar Orthoses
  • Thoracic Motion
  • horizontally-oriented facets and ribcage
    attachments to sternum limit flexion/extension,
    exc. In lower region.
  • 6-9 degrees of lateral bending and rotation in
    each segment.
  • Lumbar motion
  • Predominant motion is flexion/extension, followed
    by lateral bending and then rotation.
  • Greatest flexion/extension and least
    bending/rotation at L5-S1.

22
Lumbosacral Orthoses Types
  • Lumbosacral Orthoses
  • Chairback brace - anterior corset/apron with
    midaxillary metal uprights controls flexion
    extension
  • Williams brace - allows free flexion and limits
    extension uses lever action and abdominal
    support to decrease lordosis

23
ThoracoLumbar Orthoses Types
  • Thoracolumbar Orthoses (TLSOs)
  • Taylor brace - Thoracolumbar corset with axillary
    straps designed to limit flexion/extension Poor
    efficacy
  • Molded jackets - thermoplastic or casted highest
    efficacy to control post-fracture/injury spinal
    motion
  • Jewett Hyperextension brace - three-point
    pressure over sternum, pubis and posterior lumbar
    spine prevents flexion used with compression
    fractures not indicated with osteoporosis
    secondary to excess forces generated

24
Thoracolumbar Orthoses Utility
  • Orthoses do not achieve total or near total
    immobility. Overall fit quite variable and will
    change with usage.
  • In the face of neurological deficit, surgery is
    typically performed.
  • Even when good anatomic alignment can be
    achieved, surgery is often needed.
  • Non-surgery patients have better long-term ROM.
  • Surgical patients require 6 weeks orthosis.

25
Thoracolumbar Orthoses Utility
  • Thoracic injuries are better immobilized than
    lumbar.
  • Individuals with significant ligamentous injury
    and instability are most likely to need surgery.
  • A patient who is unstable at 6 weeks
    (post-surgery) or 12 weeks (non-surgical) despite
    orthosis use will need later surgery (although
    instability is not necessary absolute
    indication).
  • Rapid mobilization best achieved with surgery.

26
Summary
  • SCIs are an infrequent but potentially
    devastating injury that greatly stress healthcare
    and psychosocial resources.
  • Integrated systems of care are necessary to
    optimally manage care after SCI.
  • Rapid and safe mobilization with surgery and
    orthoses is key to efficient and successful
    rehabilitation.
  • Initial and long-term orthosis fitting is crucial.

27
SCI Classification
  • ASIA Classification identifies lowest level of
    normal function (C1 - S5) and degree of
    completeness
  • A - Motor and Sensory Complete
  • B - Motor Complete
  • C - Motor Incomplete but non-functional
  • D - Motor Incomplete, functional
  • E - Recovery of Neurologic Function

28
SCI Classification
  • Tetraplegia - Arms and Legs involved (C1-7)
  • Paraplegia - Trunk and Legs involved (T1-S5)
  • Central Cord - Arms predominantly involved
  • Brown Sequard - Motor weakness on one side of
    body and sensation deficits on other
  • Cauda Equina - Predominant bowel and bladder
    deficits with mild leg weakness

29
SCI Common Issues
  • Spinal Stability
  • Pulmonary
  • Neurogenic Bowel and Bladder
  • Immobility Skin Breakdown/DVT
  • Spasticity
  • Autonomic Dysreflexia/Cardiovascular
  • Bracing/Equipment
  • Heterotopic Ossification
  • Pain

30
SCI Spinal Stability
  • Stabilizing the spine is necessary before
    mobilization to prevent worsened injury and
    decrease pain.
  • Surgery has not been specifically demonstrated as
    superior to bracing, but typically performed. May
    allow earlier mobilization.
  • Spinal bracing often present for 6-12 weeks.
    Uncomfortable and difficult to maintain.

31
SCI Pulmonary
  • Pulmonary compromise is common with injuries
    involving the cervical region. Diaphragm
    innervated from C3-5. Also, muscles of chest wall
    and abdomen are needed for optimal breathing.
  • Individuals with C4 injuries (motor complete) and
    above may require lifetime ventilation. Newer
    techniques are improving this.
  • Higher short and long-term incidence of pneumonia
    in individuals with cervical injuries.

32
SCI Neurogenic B/B
  • Control of Bowel and Bladder function maintained
    at 3 levels
  • Frontal Cortex Social control empty at set
    volumes
  • Pontine Hyperreflexic B/B may empty partially,
    need assistance with full (intermittent
    catheterization, bowel program)
  • Lumbar Hyporeflexic B/B Bladder and Rectum are
    like flaccid sacs, emptying occurs with excess
    volumes Good control challenging

33
SCI Sexuality
  • Sexuality entails much more than the waterworks,
    however challenging for younger individuals to
    get beyond it.
  • Cervical and thoracic injuries are more likely to
    have reflex erectile function (rarely enough to
    achieve penetration/ejaculation).
  • Lumbar and sacral injuries rarely demonstrate
    erectile function.
  • Interventions range from Viagra to Pneumatic
    devices. Electroejaculation available.

34
SCI DVT
  • Deep venous thromboses are blood clots in the
    venous system related to vessel wall trauma,
    hypercoagulability from trauma, and immobility.
  • Occur in 40-60 of SCIs. Most common cause of
    late death. Often asymptomatic acutely. Cause
    chronic edema and pain.
  • Prophylaxis with anticoagulant is effective and
    needed for 8-12 weeks.
  • Treatment with anticoagulant is necessary for 3-6
    months.

35
SCI Skin Breakdown
  • Due to the inability of individuals with SCI to
    move/turn in bed and chairs, excess skin
    pressures occur rapidly. Skin breakdown occurs
    within 2 hours of immobility.
  • Decreased sensation limits patient input.
  • Initially, repositioning every 2 hours is needed.
  • Skin ulcers are common and take weeks to months
    to heal (25,000 each). Healing occurs with
    preventing pressure and keeping area clean/dry.

36
SCI Spasticity
  • Any upper motor neuron (brain/spinal cord) injury
    can result in an imbalance of excitatory to
    inhibitory neurotransmitter release to muscles.
  • Spasticity is increased, velocity dependent
    resistance to stretch in muscle groups.
  • Limits motion of joints and utility of preserved
    muscle strength, may be painful, may cause falls
    or functional deficits. On the other hand, may
    maintain muscle bulk, decrease pressure ulcers,
    and prevent DVTs.

37
SCI Spasticity
  • In many patient, spasticity improves over first
    3-6 months.
  • Treatment initially entails decreasing irritant
    foci that may potentiate (full bladder, pressure
    ulcer, ingrown toenail, tight fitting garments)
  • Treatment also entails stretching, positioning,
    and desensitizing extremities.
  • Numerous systemic (Baclofen, Dantrium) and focal
    (Botox, Myobloc) medications that are effective.

38
SCI Autonomic Dysreflexia
  • In individuals with SCI above T6 level, there is
    a disconnect between the sympathetic and
    parasympathetic autonomic nervous systems.
  • Stimuli of parasympathetics may set off unblocked
    sympathetic response resulting in elevated BP and
    headache. Can result in stroke/death if
    untreated.
  • All individuals with SCI experience significant
    cardiovascular deconditioning over time,
    accelerated compared to non-SCI. Close medical
    f/u and encouraging aerobic exercise is vital.

39
SCI Bracing
  • Extensive assortment of arm and leg orthoses to
    stabilize joints, substitute for weak muscles,
    and facilitate function.
  • Upper extremity devices to achieve various types
    of gripping and holding for C7 and higher
    individuals are commonly used long-term.
  • Lower extremity braces that allow functional
    transfers or walking, without the assist of
    another, are also commonly used long-term.

40
SCI Wheelchairs
  • Individuals with C6 and below SCI can
    independently propel W/Cs. Electric W/Cs are
    common above.
  • Lightweight (20 lbs) chairs are typical for
    functional mobilizers.
  • Individuals with C5 and below can commonly
    operate motor vehicles (with/without
    modifications).

41
SCI Heterotopic Ossification
  • Abnormal deposition of calcium in muscle or
    around joints in the first 4-12 weeks
    post-injury.
  • Unclear etiology, although traumatized joints and
    muscle at highest risk.
  • Symptoms include pain, swelling, and redness.
    Occurs below the level of the lesion.
  • Treatment is early identification to facilitate
    rapid mobilization and medication management.

42
SCI Pain
  • Pain is common symptom following trauma of SCI as
    well as neurologic disruption.
  • Soft tissue pain usually improved by 6 weeks.
  • Neuropathic pain common at zone of injury.
    Challenging to treat, often undertreated.
    Medications include antiepileptics (Tegretol,
    Neurontin), tricyclic antidepressants (Elavil),
    antiinflammatories, narcotics, local patches
    (Lidocaine) and liniments (Capsaisin).

43
Thank you for your attention
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