Learning Objectives     1. Identify 3 sections of vertebrae.     2. Explain the usefulness of orthotic devices.     3. List 4 basic designs for thoracolumbar support and their benefits and applications.

Support for Spinal Osteoporosis

Each year, osteoporosis causes hundreds of thousands of vertebral fractures, also known as compression or crush fractures. Vertebrae, which form the bony spine and hold the body upright, are called cervical in the neck area, thoracic in the middle back area, and lumbar in the waist and lower back area. While osteoporotic fractures can occur anywhere along the spine, they are most common in the middle or thoraco-lumbar area of the back.

If you have recently fractured a vertebra, your care will focus on relieving pain, restricting movement, increasing muscle strength, and preventing further bone loss. While fractures heal with time, the affected vertebra retains its crushed shape and affects nearby muscles, tendons, ligaments, and nerves. Depending on the number and location of fractures, the deformed vertebrae may permanently alter your posture by forcing a forward curvature of the spine known as kyphosis or a "dowager's hump."

Spinal Supports

In the first week following a vertebral fracture, your doctor will prescribe bed rest to help reduce pain. To help you get out of bed as soon as possible, your doctor may prescribe a back brace, jacket, or corset. These supports, called orthotic devices, play an important role in pain relief and rehabilitation. They relieve pain by decreasing movement in the affected area of the spine, and allow you to resume your normal activities sooner.

Spinal supports also minimize kyphosis by preventing flexion or forward bending, while encouraging extension or upward, backward bending. Supports cannot correct existing kyphosis.

Spinal supports may be purchased from a store or through a catalogue, but they are most often custom-fitted by a specialist called an orthotist. Since the benefits of a back support depend on how well it fits, the orthotist works closely with your doctor to ensure a proper fit.

If you wear your support all the time, it can weaken your back muscles. You may wear your support daily, or while exercising, or at times when support or pain relief is needed. If your back muscles get strong enough, you should be able to rely less and less on the support. Your doctor can advise you on the need for spinal support during activities.

There are four basic designs for thoraco-lumbar support: the body jacket, the Jewett-type 3-point brace, the Boston brace, and a semi-rigid support with shoulder straps. The custom-fitted total body jacket is called a clamshell because it has a front and back half. It immobilizes and supports your trunk. Since it is made of plastic and lined with foam, you need to wear a thin cotton T-shirt against your skin to absorb perspiration and allow air to circulate. This is a major consideration if you live in a climate that is hot and humid. The advantages of the body jacket are that it is good if you have multiple fractures, severe kyphosis, or existing scoliosis, and it fits without pressing on bony areas. Its disadvantages are that it is confining and bulky and may feel heavy to you even though it is made of lightweight plastic. It is also expensive: a total body jacket may cost about $1000.

The Jewett-type 3-point hyperextension brace prevents flexion and rounded shoulders and holds your body upright (which is why it is called a hyperextension brace). Because this brace is an open oval metal or plastic frame, it is less bulky and confining than the total body jacket. It is also easy to put on and allows air to circulate. Its disadvantages are that pressure sensitive areas can develop, and if you already have a spinal curvature or existing scoliosis, the brace may not fit properly. The Jewett-type brace costs about $400.

The Boston brace is similar to a body jacket except it is a softer version. It is made of two pieces of custom-molded, semi-flexible plastic.

The fourth support is an alternative to the body jacket or Jewett-type brace. It is a semi-rigid thoraco-lumbar corset that has stays along both sides of the spine and shoulder straps that remind you to keep your shoulders back.

If your fracture occurs in the lower half of your spine, your doctor may prescribe a thoraco-lumbar or lumbo-sacral corset. A corset-type brace can support your lower back, but it does not help upper body posture. There are many different lower back supports with rigid or semirigid stays. They may be made of nylon canvas or elastic; those made of elastic are easiest to use. These corsets, which cost between $100 and $300, extend from below your shoulder blades to your hips. By increasing pressure on your abdomen, they relieve pressure on your lower back and improve back muscle support even when you are at rest. These supports are less confining and easier to put on than more extensive and rigid braces. However, if you are overweight, you may find this type of support unacceptable because it must be laced tightly to work. Overweight patients do best in a rigid brace that prevents bending.

Aftercare

Once healing takes place and pain is less severe, you need to focus on increasing your activity level and improving your posture. Your rehabilitation exercises are designed to strengthen your back, abdomen, and chest muscles. Often, you may wear your support while exercising or walking because it can support your spine, relieve pain, and allow your back to rest even when you are upright.

A Posture Training Support (PTS) device may be prescribed at this time. This device has shoulder straps that connect above the waist in back where a pouch holds small weights. The weights gently pull your shoulders back and are increased as your back muscles become stronger. In addition, you should periodically squeeze your shoulder blades together while you are wearing it. The PTS can be worn while doing back strengthening exercises and reminds you to maintain good posture throughout the day.

When the orthotist fills your doctor's prescription for a brace or support, he or she will try to meet your doctor's requirements while considering your need for comfort. Ideally, the orthotist will use as little bracing as possible to achieve the desired goals of spinal support, pain relief, and prevention of flexion. In fitting the brace, the orthotist considers not only the location of the fracture, but also your hand strength, flexibility, and available caregiving assistance when deciding on the type of closure mechanism to use. Zippers, snaps, velcro, buckles, or hooks are available.

When buying your support, you should find that all adjustments are included in the initial cost. Sometimes additional padding may be necessary to relieve pressure points. Your support should be worn over a T-shirt, but under your clothes. You will find that today's loose, baggy styles, elastic waists, long tunic tops, and sweat-suits provide ideal camouflage for any type of support.

Not all insurance companies cover orthotics, and some policies only pay if you have a clause covering durable medical equipment, so check your policy. Medicare may completely or partially cover the cost of your support.

For more information on support devices, speak to your doctor about a referral to an orthopedist or a physiatrist, the specialists who most often prescribe supports.

Source: National Osteoporosis Foundation

Reprinted with permission