Transcript The Use of Spinal Orthoses After Spinal Cord Injury

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
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-1970’s.
 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
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
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)
Spinal Cord Injury
 Extensive short and long-term medical issues:
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Neurogenic bowel and bladder
Cardiovascular
Pulmonary
Integument (Skin)
Osteoporosis
Pain
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
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.
Spinal Orthoses: Principles
 Four objectives of spinal orthoses:
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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
Spinal Orthoses: Principles
 Orthoses work through the biomechanical effects
of a three-point pressure system on:
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trunk and head support
motion control
spinal realignment
partial weight transfer of the head to the trunk when in
upright
Spinal Orthoses: Principles
 Orthoses effectiveness is affected by:
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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
Spinal Orthoses: Principles
 Spinal orthoses can also have significant negative
effects:
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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
Cervical Orthoses
 To be effective they must control both gross and
intersegmental movements of the head and neck.
 C0-C1 segment involves significant flexionextension, 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).
Cervical Orthoses
 Challenges to immobilization:
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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:
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strong interest in pre-hospital immobilization systems
$40-million/year market
Cervical Orthoses: Collars
 Cervical collars [25-100% normal motion]
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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
Cervical Orthoses: Posters
 Poster Appliances: [10-28% normal motion]
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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.
Cervical Orthoses: CTO’s
 Cervicothoracic Orthoses: [10-25% normal
motion]
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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
Cervical Orthoses: Halos and Beyond
 Halo devices: [10-25% normal motion]
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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):
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improvement over casted version (lighter); may be as
effective as Halo vest; non-invasive (no pins)
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.
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 (postsurgery) 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.
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 TLO’s
(variable types) in the prevention of injuries has
not demonstrated any reduction in stresses to the
spine, muscles, or abdominal contents with these
devices.
ThoracoLumbar Orthoses
 Thoracic Motion:
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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:
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Predominant motion is flexion/extension, followed by
lateral bending and then rotation.
Greatest flexion/extension and least bending/rotation at
L5-S1.
Lumbosacral Orthoses: Types
 Lumbosacral Orthoses:
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Chairback brace - anterior corset/apron with
midaxillary metal uprights; controls flexion extension
William’s brace - allows free flexion and limits
extension; uses lever action and abdominal support to
decrease lordosis
ThoracoLumbar Orthoses: Types
 Thoracolumbar Orthoses (TLSO’s):
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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
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.
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 (postsurgery) 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.
Summary
 SCI’s 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.
SCI Classification
 ASIA Classification identifies lowest level of
normal function (C1 - S5) and degree of
completeness:
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A - Motor and Sensory Complete
B - Motor Complete
C - Motor Incomplete but non-functional
D - Motor Incomplete, functional
E - Recovery of Neurologic Function
SCI Classification
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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
SCI: Common Issues
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Spinal Stability
Pulmonary
Neurogenic Bowel and Bladder
Immobility: Skin Breakdown/DVT
Spasticity
Autonomic Dysreflexia/Cardiovascular
Bracing/Equipment
Heterotopic Ossification
Pain
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.
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.
SCI: Neurogenic B/B
 Control of Bowel and Bladder function maintained
at 3 levels:
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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
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.
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 SCI’s. 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.
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.
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 DVT’s.
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.
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.
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.
SCI: Wheelchairs
 Individuals with C6 and below SCI can
independently propel W/C’s. Electric W/C’s 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).
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.
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).
Thank you for your attention