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Orthoses for Spinal Pain
7 Orthoses for Spinal Pain Timothy Hudson, David Drake
KEY POINTS • Causation of back pain is often multifactorial and may be unidentifiable. • Although there is only limited evidence of benefit, the most consistent recommendation is that lumbar orthoses can be used in subacute back pain for a period of no more than 3 weeks to avoid paraspinal atrophy.
• When used specifically for the treatment of pain, cervical orthoses have demonstrated limited benefit and may lead to worsening function.
Although general splinting can be seen in early Egyptian culture,48 the use of spinal orthoses is noted to at least have an origin around the time of Hippocrates before the onset of the Common Era, and the time of Galen in the 2nd century.56 Although these early attempts at bracing were primarily used for clear spinal deformities, it appears that very tight corsets were also likely used to treat back pain. Although these early orthoses and treatments were made out of natural materials, modern spinal bracing often contains synthetic materials ranging from corsets to off-the-shelf braces and includes custom-molded thermoplastics. The current use of back bracing for pain is controversial at best.
predominantly in the fourth decade, with a higher rate among those with lower education.60
ORTHOSES IN LOW BACK PAIN Epidemiology Back pain is very prevalent among Americans, and internationally it represents the largest disease contributor to global disability.22 The highest prevalence of it was in Europe in 2002, whereas the lowest was in the Caribbean. Although a quarter of Americans have experienced back pain in the last 3 months,14 the prevalence in the United States was not as high as many other countries. Astonishingly, significantly disabling back pain did rise from 3.2% to 10.2% in North Carolina, comparing 1992 data to 2006 data.20 These authors implicate rising obesity and depression but also the possibility of increased symptom awareness. Although this does not seem to affect health care utilization, the growing prevalence does affect health care spending and the overall volume of surgery. Identification of the pathology includes a thorough history; a physical examination looking for the presence of neurologic compromise such as weakness or numbness; and, if specific pathology is suspected, additional, confirmatory testing. This testing may include radiographs, magnetic resonance imaging, or electromyography, but imaging is not typically indicated for nonspecific back pain.9 Causation in low back pain does seem to have a correlation with intervertebral disc pathology,22 although this is clearly unreliable as a predictor.57 Other causes seem to be facet pathology and sacroiliac dysfunction,10 and radiculopathy and myofascial disorders can play some role. Its incidence is
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Treatments of Low Back Pain General management of back pain can be differentiated based on whether the pain is acute or chronic. In general, self-care is the first step for all types of back pain, including staying active, providing education, and application of modalities such as heat.9 Medications such as nonsteroidal antiinflammatory drugs and acetaminophen are considered first line for all types of back pain. For acute pain, muscle relaxants may be indicated, whereas antidepressant and antiepileptic medications may be more useful in chronic disease. In difficult cases, spinal cord stimulators have been shown to be efficacious in chronic low back pain.1 Although 36% of rehabilitation physicians surveyed in France would use lumbar orthoses for treatment in back pain, the indications for use are neither clear nor rigorously studied.39 For neurosurgeons, orthoses may provide an alternative to surgery.13 Examples of two styles of lumbar orthoses are presented in Figs. 7.1 and 7.2, which show nonrigid and rigid braces, respectively. Fig. 7.1 is a corset style and Fig. 7.2 is a custom-molded, clam-shell–style orthosis. A proposed prominent mechanism of action for the use of lumbar spine orthoses in pain management is to decrease motion over individual segments of the spine, allowing reduction of inflammation and encouraging the process of healing.39 In some regards, this is similar to bracing for spinal fracture, which is also limited in evidence38 and has been shown to improve short-term and medium-term function, even compared with surgery.16,46,51,61 Decisions to brace, in a limited survey of physiatrists, were often related to the functional examination, radiographic findings, or magnetic resonance imaging (MRI) findings.39 Other mechanisms that have been suggested range from increasing intraabdominal pressure to reducing muscle fatigue, but research supporting these has been inconclusive.55
Range-of-Motion Restrictions Significant reduction of range of motion, particularly axial rotation, is an assumed mechanism for treatment of back pain with bracing. With immobilization being the primary goal of lumbar bracing, the studies
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causing further injury is a concern with orthoses.39 Thus their use has been controversial in the literature. Last, in healthy subjects, studies have shown that flexible and rigid lumbar orthoses have no effect on gait initiation or dynamics.12
Spinal Column Unloading
Figure 7.1 Flexible lumbar corset. (From Lusardi M, Jorge M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, 3rd ed. Philadelphia, Elsevier, 2013, Fig. 13-9A.)
One of the theories of pain relief in the lumbar spine is spinal column unloading. As mentioned previously, the evidence is not strong for this being a major component of pain relief. Unloading can occur through direct or indirect methods. In direct methods, the orthosis bears the weight of the forces normally transmitted through the spine, whereas indirect methods are believed to use increased intraabdominal pressure to unload the axial spine. Much research has been done to offer validity, mostly without producing convincing data. This seems to arise from a Nachemson’s study in 1964 that demonstrated a 25% decrease of disc pressure and an increase in intraabdominal pressure with an inflatable corset.37 Although the indirect method has been popularized through the use of lumbar support corsets, its use has not significantly been shown to increase total intraabdominal pressure or change compression forces,55 and a proof of concept has not been achieved. There is conflicting evidence about muscle activity. Some evidence shows a reduction in muscle activity, but other reports show no change.28
Change in Proprioception Another reason for use of a lumbar orthosis in back pain is the alteration of the sensation of spine movement. This is a common factor in choosing to treat or prevent low back pain with corsets or other bracing. This philosophy has been partly predicated on observed differences in spinal proprioception between those who have low back pain and those who do not.21,32 This has been correlated with delayed lumbar trunk muscle response times in those with chronic pain,41 which could be related to changes in the afferent input from the muscle spindle.4 As suspected, the use of a lumbosacral orthosis (LSO) does improve overall lumbar proprioception.8,33 Braces oriented toward proprioceptive feedback can provide pain relief, whereas the more rigid, inextensible braces can provide a more beneficial effect on patient dysfunction.35
Pain Reduction
Figure 7.2 Rigid lumbar brace: prefabricated thoracolumbosacral orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
are unconvincing and variable regarding its ability to reduce range of motion. A review of the literature demonstrated control could be achieved in flexion, extension, and lateral bending, but not rotation.55 Although larger gross limitation occurred with lumbar orthoses restricting extension motion, the results did vary, and a custom-made stay brace seemed to provide the greatest ROM limitation.50 In an older study, smaller, intersegmental motion could not be controlled with bracing.3 Additionally, the loss of range of motion causing the symptoms to worsen or
So far, studies have not borne a consistent standard for the reason for or use of orthoses in the treatment of low back pain; yet, many providers seem to prescribe these, most likely based on their clinical experience.39 First, the type of brace does likely matter. Nonrigid, inelastic bracing for acute pain can provide some relief in the short term without altering back function, in comparison to patients with no back pain over a 2-week period.29 However, the use of an inextensible lumbar sacral orthosis that is made of a material that cannot be stretched was associated with a clinically significant reduction in the Oswestry Disability Index, though the pain reduction was not significantly different from standard care or extensible LSOs made of neoprene and lycra.35 The expert consensus is that there is no convincing scientific evidence that lumbar support should be used primarily for the treatment of low back pain but rather on a case-by-case basis in subacute back pain or for secondary prevention.31 Regardless, neurosurgeons are recommended to use bracing in lieu of surgery,13 because some evidence for subacute low back pain does demonstrate pain medication reduction.5 The use of lumbar orthoses to prevent back pain is also questionable. In a meta-analysis, the use of back belts only tended to reduce sick days, but not in a statistically significant manner, and did not reduce the number of episodes.49 However, even reducing the number of sick days could improve overall cost-effectiveness in work environments.43 The effect seems to be in the consistency of use, which when studied is directly correlated with the patient belief that the bracing is beneficial.44
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Consistently, further reviews have shown that the only beneficial treatment for the prevention of back pain with good evidence is exercise.2
motion. Although some cervical spine devices have been promoted for traction, they are not included in this chapter.
Side Effects
Immobilization
There are several concerns regarding the use of orthoses for low back pain. The most predominant is the possibility of muscle wasting in the trunk muscles. The literature is contradictory but overall does not support a weakening effect on trunk muscles.19 A study by Fayolle-Minon and Calmels19 did not demonstrate the development of significant muscle weakness with brace use over the period of 3 weeks. Although studies have reported no effect on long-term issues by using corsets for 6 months,59 there is some suggestive evidence in other studies for the development of weakness over prolonged periods of brace wear.18 Other side effects that have not been not well studied could theoretically include pain, skin breakdown, gastrointestinal disorders, decreased vital capacity, increased lower extremity venous pressure, high blood pressure, and increased heart rates. Therefore general consensus recommendations include using these braces only intermittently and monitoring daily living parameters such as skin, pain, and blood pressure during use. Braces should likely not be consistently worn for more than 3 weeks by individuals with chronic back pain.
Cervical spine immobilization is the primary indication for cervical orthoses. The type of orthoses used may vary depending on the level of the cervical vertebrae one wishes to immobilize and the reason for immobilization (e.g., trauma, surgery). In a systematic review using a rating scale defining five levels of immobilization—poor (minimal immobilization limits [MIL] < 20%), fair (MIL 20%–40%), moderate (MIL 40%–60%), substantial (MIL 60%–80%), and nearly complete (MIL ≥ 80%),23 Holla et al.24 found that soft collars (Fig. 7.3) poorly limited cervical range of motion in all planes, whereas cervico–high-thoracic (Figs. 7.4 and 7.5) and cervico–low-thoracic (Fig. 7.6) orthoses both showed a moderate restriction for flexion and extension but poor restriction for lateral bending, though the cervico–low-thoracic orthoses did a better job restricting rotation. They also concluded that all craniothoracic devices for nonambulatory patients restricted cervical spine movement substantially in all directions, as did vests with noninvasive skull fixation. They did not address halo vests with skull pins.24 Evaluating the literature on stabilizing cervical fractures, Karimi et al.27 specifically researched the use of cervical orthoses in fractures and spinal injuries. They evaluated the quality of the studies with the Downs and Black17 Assessment of Multiple Systematic Reviews (AMSTAR) for original research and review articles.47 Findings were primarily focused on the use of the halo vest orthosis and its side effects. The halo orthosis was found to have the greatest immobilization, particularly in upper cervical injuries; however, it was also associated with the most complications, such as pin infection, pressure sores, and dysphagia. Although the Minerva style (Fig. 7.6) is better tolerated and does limit motion significantly, particularly in the lower cervical spine, physicians
Outcomes Classically, the natural history of back pain is that it lasts approximately 2 weeks in 62% of cases,15 and relapses do occur within a year in most cases.53 Three out of four patients who experience pain at 8 weeks will have pain at 12 months.58 Although the pain is volatile for the first 2 to 6 months, it will plateau and stabilize after about 6 months. Historically studies have shown controversial results regarding the use of lumbar orthoses for back pain.30 Early work has supported the use of lumbar supports for back pain by showing relief of symptoms, though objective measures were lacking.34 Lumbar supports may be better than no treatment, but there is no clear benefit compared with other traditional treatments.54 Chiropractic care also seems to be better than massage or corset use in the short run.26 In physical measures, however, there are no differences among these methods.40 Chiropractic care and myofascial therapy were equally effective apart or together, and back school (a weekly meeting for three weeks reviewing anatomy, posture, exercises, and dynamic function) is as effective as three manual treatments.25 Physical therapy has been shown to help in the short term, but less so over the long term, and the benefits of corsets are equivocal over a 4-week period.11 The use of lumbar belts does not enhance the ability to work,42 but because lumbar bracing can reduce overall paraspinal muscle activity,28 this may allow for appropriate healing and protection from strain. Back bracing does seem to be preferred over natural treatment and helpful for symptom management.52
Summary The use of lumbar bracing is controversial for low back pain, and determining the benefits of bracing is complicated by the heterogeneous causes of back pain and by the high likelihood of pain recurrence. Appropriate workup is necessary to provide the most specific treatment possible. However, bracing may be of benefit during the subacute phase of pain, within the first 3 weeks of onset. Longer-term use of bracing in low back pain is not indicated and may carry some risk of muscle atrophy.
CERVICAL ORTHOSES Orthotics for the cervical spine serve either of two purposes: (1) to immobilize or limit motion or (2) for pain, which often involves limiting
Figure 7.3 Soft cervical collar. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
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Figure 7.4 Miami J-style cervical orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
Figure 7.6 Sternooccipitomandibular immobilizer (SOMI) brace. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
Figure 7.5 Aspen cervical orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
must weigh the benefits of immobility against the possible complications associated with the orthosis.27 Although stabilizing cervical fractures appears to be an indication for cervical orthoses, it is not clear that they are necessary after fusion surgery. Camara et al.6 reviewed the available literature related to
postfusion immobilization and outcomes. Unfortunately, many of the articles were of lower quality. However, one study supported the conclusion that external bracing is not associated with improved fusion rates after ACDF. Campbell et al.7 performed a retrospective analysis of 257 patients divided into braced (149 patients) and nonbraced (108 patients) groups without randomization after decompression and arthrodesis using allograft and an anterior cervical plate. The rate of fusion at 6 and 24 months was not statistically different between braced and nonbraced groups. They concluded that external bracing after ACDF is not associated with improved fusion rates.7 Camara et al.6 found minimal limitations in the ability of this study to retrospectively compare fusion rates between braced and nonbraced groups and therefore suggested a high likelihood of bias. The remaining six studies this group reviewed were reported to be of very low quality of evidence. Despite this, they recommend against the routine use of external cervical orthoses after anterior cervical disc fusion because of a lack of improved fusion rates associated with external bracing after surgery.6 Clearly more research is necessary to definitively determine the need for postfusion cervical orthoses.
Pain Often with pain, orthoses are used to limit any painful motion. Patients commonly self-treat with a soft orthosis, although research does not support their effectiveness in limiting motion. The benefits, which are not well established for pain alone, must be weighed with the risks. Although bracing the neck may be necessary for healing either after trauma or postsurgically, doing so for pain only is not entirely without biomechanical effects on the gait. Bracing the neck and torso in healthy
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young adults has been shown to affect gait patterns, slowing the gait to replicate that of elderly individuals.45 It was also found that bracing increased activity in erector spinae, decreased abdominal muscle activity, and caused lower trunk muscle coactivation,36 all of which, if done over the long term, may lead to other biomechanical problems.
CONCLUSION All but soft cervical orthoses limit motion in differing planes to variable degrees. The halo orthosis is the most limiting, particularly
for upper cervical spine injuries, although it is also responsible for the most complications. The necessity of postfusion cervical orthoses has yet to be definitively determined, but there is suggestive evidence that they may not be necessary for proper fusion to occur. Immobilization only for pain without an anatomical reason may lead to gait abnormalities and possible future problems within the spinal and kinetic chain. A complete reference list can be found online at ExpertConsult.com.
CHAPTER 7 Orthoses for Spinal Pain
REFERENCES 1. Al-Kaisy A, Van Buyten JP, Smet I, et al. Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study. Pain Med. 2014;15(3):347–354. 2. Bigos SJ, Holland J, Holland C, et al. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J. 2009;9(2):147–168. 3. Brown T, Norton PL. The immobilizing efficiency of back braces; their effect on the posture and motion of the lumbosacral spine. J Bone Joint Surg Am. 1957;39-A(1):111–139. 4. Brumagne S, Cordo P, Lysens R, et al. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine. 2000;25(8):989–994. 5. Calmels P, Queneau P, Hamonet C, et al. Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine. 2009;34(3):215–220. 6. Camara R, Ajayi OO, Asgarzadie F. Are external cervical orthoses necessary after anterior cervical discectomy and fusion: a review of the literature. Cureus. 2016;8(7):e688. 7. Campbell MJ, Carreon LY, Traynelis V, et al. Use of cervical collar after single-level anterior cervical fusion with plate: is it necessary? Spine. 2009;34(1):43–48. 8. Cholewicki J, Shah KR, McGill KC. The effects of a 3-week use of lumbosacral orthoses on proprioception in the lumbar spine. J Orthop Sports Phys Ther. 2006;36(4):225–231. 9. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. 10. Cooper G. Lower back pain: an overview of the most common causes. In: Non-Operative Treatment of the Lumbar Spine. Springer; 2015:11–13. 11. Coxhead CE, Inskip H, Meade TW, et al. Multicentre trial of physiotherapy in the management of sciatic symptoms. Lancet. 1981;1(8229):1065–1068. 12. Cusin E, Do MC, Rougier PR. How does wearing a lumbar orthosis interfere with gait initiation? Ergonomics. 2016;1–7. 13. Dailey AT, Ghogawala Z, Choudhri TF, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14: brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine. 2014;21(1):91–101. 14. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31(23): 2724–2727. 15. Dillane JB, Fry J, Kalton G. Acute back syndrome—a study from general practice. Br Med J. 1966;2(5505):82–84. 16. Dionyssiotis Y, Trovas G, Thoma S, et al. Prospective study of spinal orthoses in women. Prosthet Orthot Int. 2015;39(6):487–495. 17. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377–384. 18. Eisinger DB, Kumar R, Woodrow R. Effect of lumbar orthotics on trunk muscle strength. Am J Phys Med Rehabil. 1996;75(3):194–197. 19. Fayolle-Minon I, Calmels P. Effect of wearing a lumbar orthosis on trunk muscles: study of the muscle strength after 21 days of use on healthy subjects. Joint Bone Spine. 2008;75(1):58–63. 20. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251–258. 21. Gill KP, Callaghan MJ. The measurement of lumbar proprioception in individuals with and without low back pain. Spine. 1998;23(3):371–377. 22. Gore M, Sadosky A, Stacey BR, et al. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine. 2012;37(11):E668–E677. 23. Holla M, Huisman JM, Hosman AJ. A validated classification for external immobilization of the cervical spine. Evid Based Spine Care J. 2013;4(2):72–77.
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24. Holla M, Huisman JM, Verdonschot N, et al. The ability of external immobilizers to restrict movement of the cervical spine: a systematic review. Eur Spine J. 2016;25(7):2023–2036. 25. Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine. 2002;27(11):1142–1148. 26. Hsieh CY, Phillips RB, Adams AH, et al. Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther. 1992;15(1):4–9. 27. Karimi MT, Kamali M, Fatoye F. Evaluation of the efficiency of cervical orthoses on cervical fracture: a review of literature. J Craniovertebr Junction Spine. 2016;7(1):13–19. 28. Kawaguchi Y, Gejo R, Kanamori M, et al. Quantitative analysis of the effect of lumbar orthosis on trunk muscle strength and muscle activity in normal subjects. J Orthop Sci. 2002;7(4):483–489. 29. Kawchuk GN, Edgecombe TL, Wong AY, et al. A non-randomized clinical trial to assess the impact of nonrigid, inelastic corsets on spine function in low back pain participants and asymptomatic controls. Spine J. 2015;15(10):2222–2227. 30. Koes B, Van Den Hoogen H. Efficacy of bed rest and orthoses of low-back pain: a review of randomized clinical trials. Eur J Phys Med Rehabil. 1994;4(3):86–93. 31. Lanhers C, Boutevillain L, Pereira B, et al. Lumbar support and nonspecific low back pain: evidence for daily practice. Ann Phys Rehabil Med. 2016;59S:e29. 32. Lee AS, Cholewicki J, Reeves NP, et al. Comparison of trunk proprioception between patients with low back pain and healthy controls. Arch Phys Med Rehabil. 2010;91(9):1327–1331. 33. McNair PJ, Heine PJ. Trunk proprioception: enhancement through lumbar bracing. Arch Phys Med Rehabil. 1999;80(1):96–99. 34. Million R, Nilsen KH, Jayson MI, et al. Evaluation of low back pain and assessment of lumbar corsets with and without back supports. Ann Rheum Dis. 1981;40(5):449–454. 35. Morrisette DC, Cholewicki J, Logan S, et al. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine. 2014;39(21):1733–1742. 36. Morrison S, Russell DM, Kelleran K, et al. Bracing of the trunk and neck has a differential effect on head control during gait. J Neurophysiol. 2015;114(3):1773–1783. 37. Nachemson A, Morris JM. In vivo measurements of intradiscal pressure. discometry, a method for the determination of pressure in the lower lumbar discs. J Bone Joint Surg Am. 1964;46:1077–1092. 38. Newman M, Minns Lowe C, Barker K. Spinal orthoses for vertebral osteoporosis and osteoporotic vertebral fracture: A systematic review. Arch Phys Med Rehabil. 2016;97(6):1013–1025. 39. Phaner V, Fayolle-Minon I, Lequang B, et al. Are there indications (other than scoliosis) for rigid orthopaedic brace treatment in chronic, mechanical low back pain? Ann Phys Rehabil Med. 2009;52(5):382–393. 40. Pope MH, Phillips RB, Haugh LD, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine. 1994;19(22):2571–2577. 41. Radebold A, Cholewicki J, Polzhofer GK, et al. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine. 2001;26(7):724–730. 42. Reyna JR Jr, Leggett SH, Kenney K, et al. The effect of lumbar belts on isolated lumbar muscle. Strength and dynamic capacity. Spine. 1995;20(1):68–73. 43. Roelofs PD, Bierma-Zeinstra SM, van Poppel MN, et al. Cost-effectiveness of lumbar supports for home care workers with recurrent low back pain: an economic evaluation alongside a randomized-controlled trial. Spine. 2010;35(26):E1619–E1626. 44. Roelofs PD, van Poppel MN, Bierma-Zeinstra SM, et al. Determinants of the intention for using a lumbar support among home care workers with recurrent low back pain. Eur Spine J. 2010;19(9):1502–1507.
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45. Russell DM, Kelleran KJ, Morrison S. Bracing the trunk and neck in young adults leads to a more aged-like gait. Gait Posture. 2016;49:388–393. 46. Rzewuska M, Ferreira M, McLachlan AJ, et al. The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis. Eur Spine J. 2015;24(4):702–714. 47. Seo HJ, Kim KU. Quality assessment of systematic reviews or metaanalyses of nursing interventions conducted by Korean reviewers. BMC Med Res Method. 2012;12:129. 48. Smith GE. The most ancient splints. Br Med J. 1908;1(2465):732–736, 732. 49. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: A systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208. 50. Terai T, Yamada H, Asano K, et al. Effectiveness of three types of lumbar orthosis for restricting extension motion. Eur J Orthop Surg Traumatol. 2014;24(suppl 1):S239–S243. 51. Valentin GH, Pedersen LN, Maribo T. Wearing an active spinal orthosis improves back extensor strength in women with osteoporotic vertebral fractures. Prosthet Orthot Int. 2014;38(3):232–238. 52. Valle-Jones JC, Walsh H, O’Hara J, et al. Controlled trial of a back support (‘Lumbotrain’) in patients with non-specific low back pain. Curr Med Res Op. 1992;12(9):604–613.
53. van den Hoogen HJ, Koes BW, van Eijk JT, et al. On the course of low back pain in general practice: a one year follow up study. Ann Rheum Dis. 1998;57(1):13–19. 54. van Duijvenbode IC, Jellema P, van Poppel MN, et al. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008;(2):CD001823. 55. van Poppel MN, de Looze MP, Koes BW, et al. Mechanisms of action of lumbar supports: a systematic review. Spine. 2000;25(16):2103–2113. 56. Vasiliadis ES, Grivas TB, Kaspiris A. Historical overview of spinal deformities in ancient Greece. Scoliosis. 2009;4:6. 57. Von Korff M. Studying the natural history of back pain. Spine. 1994;19(18):2041S–2046S. 58. Wahlgren DR, Atkinson JH, Epping-Jordan JE, et al. One-year follow-up of first onset low back pain. Pain. 1997;73(2):213–221. 59. Walsh NE, Schwartz RK. The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace. Am J Phys Med Rehabil. 1990;69(5):245–250. 60. Werber A, Schiltenwolf M. Treatment of lower back pain—the gap between guideline-based treatment and medical care reality. Healthcare. 2016;4(3). 61. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am. 2015;97(1):3–9.
KEY POINTS • Causation of back pain is often multifactorial and may be unidentifiable. • Although there is only limited evidence of benefit, the most consistent recommendation is that lumbar orthoses can be used in subacute back pain for a period of no more than 3 weeks to avoid paraspinal atrophy.
• When used specifically for the treatment of pain, cervical orthoses have demonstrated limited benefit and may lead to worsening function.
Although general splinting can be seen in early Egyptian culture,48 the use of spinal orthoses is noted to at least have an origin around the time of Hippocrates before the onset of the Common Era, and the time of Galen in the 2nd century.56 Although these early attempts at bracing were primarily used for clear spinal deformities, it appears that very tight corsets were also likely used to treat back pain. Although these early orthoses and treatments were made out of natural materials, modern spinal bracing often contains synthetic materials ranging from corsets to off-the-shelf braces and includes custom-molded thermoplastics. The current use of back bracing for pain is controversial at best.
predominantly in the fourth decade, with a higher rate among those with lower education.60
ORTHOSES IN LOW BACK PAIN Epidemiology Back pain is very prevalent among Americans, and internationally it represents the largest disease contributor to global disability.22 The highest prevalence of it was in Europe in 2002, whereas the lowest was in the Caribbean. Although a quarter of Americans have experienced back pain in the last 3 months,14 the prevalence in the United States was not as high as many other countries. Astonishingly, significantly disabling back pain did rise from 3.2% to 10.2% in North Carolina, comparing 1992 data to 2006 data.20 These authors implicate rising obesity and depression but also the possibility of increased symptom awareness. Although this does not seem to affect health care utilization, the growing prevalence does affect health care spending and the overall volume of surgery. Identification of the pathology includes a thorough history; a physical examination looking for the presence of neurologic compromise such as weakness or numbness; and, if specific pathology is suspected, additional, confirmatory testing. This testing may include radiographs, magnetic resonance imaging, or electromyography, but imaging is not typically indicated for nonspecific back pain.9 Causation in low back pain does seem to have a correlation with intervertebral disc pathology,22 although this is clearly unreliable as a predictor.57 Other causes seem to be facet pathology and sacroiliac dysfunction,10 and radiculopathy and myofascial disorders can play some role. Its incidence is
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Treatments of Low Back Pain General management of back pain can be differentiated based on whether the pain is acute or chronic. In general, self-care is the first step for all types of back pain, including staying active, providing education, and application of modalities such as heat.9 Medications such as nonsteroidal antiinflammatory drugs and acetaminophen are considered first line for all types of back pain. For acute pain, muscle relaxants may be indicated, whereas antidepressant and antiepileptic medications may be more useful in chronic disease. In difficult cases, spinal cord stimulators have been shown to be efficacious in chronic low back pain.1 Although 36% of rehabilitation physicians surveyed in France would use lumbar orthoses for treatment in back pain, the indications for use are neither clear nor rigorously studied.39 For neurosurgeons, orthoses may provide an alternative to surgery.13 Examples of two styles of lumbar orthoses are presented in Figs. 7.1 and 7.2, which show nonrigid and rigid braces, respectively. Fig. 7.1 is a corset style and Fig. 7.2 is a custom-molded, clam-shell–style orthosis. A proposed prominent mechanism of action for the use of lumbar spine orthoses in pain management is to decrease motion over individual segments of the spine, allowing reduction of inflammation and encouraging the process of healing.39 In some regards, this is similar to bracing for spinal fracture, which is also limited in evidence38 and has been shown to improve short-term and medium-term function, even compared with surgery.16,46,51,61 Decisions to brace, in a limited survey of physiatrists, were often related to the functional examination, radiographic findings, or magnetic resonance imaging (MRI) findings.39 Other mechanisms that have been suggested range from increasing intraabdominal pressure to reducing muscle fatigue, but research supporting these has been inconclusive.55
Range-of-Motion Restrictions Significant reduction of range of motion, particularly axial rotation, is an assumed mechanism for treatment of back pain with bracing. With immobilization being the primary goal of lumbar bracing, the studies
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causing further injury is a concern with orthoses.39 Thus their use has been controversial in the literature. Last, in healthy subjects, studies have shown that flexible and rigid lumbar orthoses have no effect on gait initiation or dynamics.12
Spinal Column Unloading
Figure 7.1 Flexible lumbar corset. (From Lusardi M, Jorge M, Nielsen C: Orthotics and Prosthetics in Rehabilitation, 3rd ed. Philadelphia, Elsevier, 2013, Fig. 13-9A.)
One of the theories of pain relief in the lumbar spine is spinal column unloading. As mentioned previously, the evidence is not strong for this being a major component of pain relief. Unloading can occur through direct or indirect methods. In direct methods, the orthosis bears the weight of the forces normally transmitted through the spine, whereas indirect methods are believed to use increased intraabdominal pressure to unload the axial spine. Much research has been done to offer validity, mostly without producing convincing data. This seems to arise from a Nachemson’s study in 1964 that demonstrated a 25% decrease of disc pressure and an increase in intraabdominal pressure with an inflatable corset.37 Although the indirect method has been popularized through the use of lumbar support corsets, its use has not significantly been shown to increase total intraabdominal pressure or change compression forces,55 and a proof of concept has not been achieved. There is conflicting evidence about muscle activity. Some evidence shows a reduction in muscle activity, but other reports show no change.28
Change in Proprioception Another reason for use of a lumbar orthosis in back pain is the alteration of the sensation of spine movement. This is a common factor in choosing to treat or prevent low back pain with corsets or other bracing. This philosophy has been partly predicated on observed differences in spinal proprioception between those who have low back pain and those who do not.21,32 This has been correlated with delayed lumbar trunk muscle response times in those with chronic pain,41 which could be related to changes in the afferent input from the muscle spindle.4 As suspected, the use of a lumbosacral orthosis (LSO) does improve overall lumbar proprioception.8,33 Braces oriented toward proprioceptive feedback can provide pain relief, whereas the more rigid, inextensible braces can provide a more beneficial effect on patient dysfunction.35
Pain Reduction
Figure 7.2 Rigid lumbar brace: prefabricated thoracolumbosacral orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
are unconvincing and variable regarding its ability to reduce range of motion. A review of the literature demonstrated control could be achieved in flexion, extension, and lateral bending, but not rotation.55 Although larger gross limitation occurred with lumbar orthoses restricting extension motion, the results did vary, and a custom-made stay brace seemed to provide the greatest ROM limitation.50 In an older study, smaller, intersegmental motion could not be controlled with bracing.3 Additionally, the loss of range of motion causing the symptoms to worsen or
So far, studies have not borne a consistent standard for the reason for or use of orthoses in the treatment of low back pain; yet, many providers seem to prescribe these, most likely based on their clinical experience.39 First, the type of brace does likely matter. Nonrigid, inelastic bracing for acute pain can provide some relief in the short term without altering back function, in comparison to patients with no back pain over a 2-week period.29 However, the use of an inextensible lumbar sacral orthosis that is made of a material that cannot be stretched was associated with a clinically significant reduction in the Oswestry Disability Index, though the pain reduction was not significantly different from standard care or extensible LSOs made of neoprene and lycra.35 The expert consensus is that there is no convincing scientific evidence that lumbar support should be used primarily for the treatment of low back pain but rather on a case-by-case basis in subacute back pain or for secondary prevention.31 Regardless, neurosurgeons are recommended to use bracing in lieu of surgery,13 because some evidence for subacute low back pain does demonstrate pain medication reduction.5 The use of lumbar orthoses to prevent back pain is also questionable. In a meta-analysis, the use of back belts only tended to reduce sick days, but not in a statistically significant manner, and did not reduce the number of episodes.49 However, even reducing the number of sick days could improve overall cost-effectiveness in work environments.43 The effect seems to be in the consistency of use, which when studied is directly correlated with the patient belief that the bracing is beneficial.44
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Consistently, further reviews have shown that the only beneficial treatment for the prevention of back pain with good evidence is exercise.2
motion. Although some cervical spine devices have been promoted for traction, they are not included in this chapter.
Side Effects
Immobilization
There are several concerns regarding the use of orthoses for low back pain. The most predominant is the possibility of muscle wasting in the trunk muscles. The literature is contradictory but overall does not support a weakening effect on trunk muscles.19 A study by Fayolle-Minon and Calmels19 did not demonstrate the development of significant muscle weakness with brace use over the period of 3 weeks. Although studies have reported no effect on long-term issues by using corsets for 6 months,59 there is some suggestive evidence in other studies for the development of weakness over prolonged periods of brace wear.18 Other side effects that have not been not well studied could theoretically include pain, skin breakdown, gastrointestinal disorders, decreased vital capacity, increased lower extremity venous pressure, high blood pressure, and increased heart rates. Therefore general consensus recommendations include using these braces only intermittently and monitoring daily living parameters such as skin, pain, and blood pressure during use. Braces should likely not be consistently worn for more than 3 weeks by individuals with chronic back pain.
Cervical spine immobilization is the primary indication for cervical orthoses. The type of orthoses used may vary depending on the level of the cervical vertebrae one wishes to immobilize and the reason for immobilization (e.g., trauma, surgery). In a systematic review using a rating scale defining five levels of immobilization—poor (minimal immobilization limits [MIL] < 20%), fair (MIL 20%–40%), moderate (MIL 40%–60%), substantial (MIL 60%–80%), and nearly complete (MIL ≥ 80%),23 Holla et al.24 found that soft collars (Fig. 7.3) poorly limited cervical range of motion in all planes, whereas cervico–high-thoracic (Figs. 7.4 and 7.5) and cervico–low-thoracic (Fig. 7.6) orthoses both showed a moderate restriction for flexion and extension but poor restriction for lateral bending, though the cervico–low-thoracic orthoses did a better job restricting rotation. They also concluded that all craniothoracic devices for nonambulatory patients restricted cervical spine movement substantially in all directions, as did vests with noninvasive skull fixation. They did not address halo vests with skull pins.24 Evaluating the literature on stabilizing cervical fractures, Karimi et al.27 specifically researched the use of cervical orthoses in fractures and spinal injuries. They evaluated the quality of the studies with the Downs and Black17 Assessment of Multiple Systematic Reviews (AMSTAR) for original research and review articles.47 Findings were primarily focused on the use of the halo vest orthosis and its side effects. The halo orthosis was found to have the greatest immobilization, particularly in upper cervical injuries; however, it was also associated with the most complications, such as pin infection, pressure sores, and dysphagia. Although the Minerva style (Fig. 7.6) is better tolerated and does limit motion significantly, particularly in the lower cervical spine, physicians
Outcomes Classically, the natural history of back pain is that it lasts approximately 2 weeks in 62% of cases,15 and relapses do occur within a year in most cases.53 Three out of four patients who experience pain at 8 weeks will have pain at 12 months.58 Although the pain is volatile for the first 2 to 6 months, it will plateau and stabilize after about 6 months. Historically studies have shown controversial results regarding the use of lumbar orthoses for back pain.30 Early work has supported the use of lumbar supports for back pain by showing relief of symptoms, though objective measures were lacking.34 Lumbar supports may be better than no treatment, but there is no clear benefit compared with other traditional treatments.54 Chiropractic care also seems to be better than massage or corset use in the short run.26 In physical measures, however, there are no differences among these methods.40 Chiropractic care and myofascial therapy were equally effective apart or together, and back school (a weekly meeting for three weeks reviewing anatomy, posture, exercises, and dynamic function) is as effective as three manual treatments.25 Physical therapy has been shown to help in the short term, but less so over the long term, and the benefits of corsets are equivocal over a 4-week period.11 The use of lumbar belts does not enhance the ability to work,42 but because lumbar bracing can reduce overall paraspinal muscle activity,28 this may allow for appropriate healing and protection from strain. Back bracing does seem to be preferred over natural treatment and helpful for symptom management.52
Summary The use of lumbar bracing is controversial for low back pain, and determining the benefits of bracing is complicated by the heterogeneous causes of back pain and by the high likelihood of pain recurrence. Appropriate workup is necessary to provide the most specific treatment possible. However, bracing may be of benefit during the subacute phase of pain, within the first 3 weeks of onset. Longer-term use of bracing in low back pain is not indicated and may carry some risk of muscle atrophy.
CERVICAL ORTHOSES Orthotics for the cervical spine serve either of two purposes: (1) to immobilize or limit motion or (2) for pain, which often involves limiting
Figure 7.3 Soft cervical collar. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
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Figure 7.4 Miami J-style cervical orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
Figure 7.6 Sternooccipitomandibular immobilizer (SOMI) brace. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
Figure 7.5 Aspen cervical orthosis. (From Botte MJ, Garfin SR, Bergmann K, et al. Spinal orthoses for traumatic and degenerative disease. In Herkowitz HN, Garfin SR, Balderston RA, et al., eds. The Spine. 4th ed. Philadelphia: WB Saunders; 1999.)
must weigh the benefits of immobility against the possible complications associated with the orthosis.27 Although stabilizing cervical fractures appears to be an indication for cervical orthoses, it is not clear that they are necessary after fusion surgery. Camara et al.6 reviewed the available literature related to
postfusion immobilization and outcomes. Unfortunately, many of the articles were of lower quality. However, one study supported the conclusion that external bracing is not associated with improved fusion rates after ACDF. Campbell et al.7 performed a retrospective analysis of 257 patients divided into braced (149 patients) and nonbraced (108 patients) groups without randomization after decompression and arthrodesis using allograft and an anterior cervical plate. The rate of fusion at 6 and 24 months was not statistically different between braced and nonbraced groups. They concluded that external bracing after ACDF is not associated with improved fusion rates.7 Camara et al.6 found minimal limitations in the ability of this study to retrospectively compare fusion rates between braced and nonbraced groups and therefore suggested a high likelihood of bias. The remaining six studies this group reviewed were reported to be of very low quality of evidence. Despite this, they recommend against the routine use of external cervical orthoses after anterior cervical disc fusion because of a lack of improved fusion rates associated with external bracing after surgery.6 Clearly more research is necessary to definitively determine the need for postfusion cervical orthoses.
Pain Often with pain, orthoses are used to limit any painful motion. Patients commonly self-treat with a soft orthosis, although research does not support their effectiveness in limiting motion. The benefits, which are not well established for pain alone, must be weighed with the risks. Although bracing the neck may be necessary for healing either after trauma or postsurgically, doing so for pain only is not entirely without biomechanical effects on the gait. Bracing the neck and torso in healthy
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young adults has been shown to affect gait patterns, slowing the gait to replicate that of elderly individuals.45 It was also found that bracing increased activity in erector spinae, decreased abdominal muscle activity, and caused lower trunk muscle coactivation,36 all of which, if done over the long term, may lead to other biomechanical problems.
CONCLUSION All but soft cervical orthoses limit motion in differing planes to variable degrees. The halo orthosis is the most limiting, particularly
for upper cervical spine injuries, although it is also responsible for the most complications. The necessity of postfusion cervical orthoses has yet to be definitively determined, but there is suggestive evidence that they may not be necessary for proper fusion to occur. Immobilization only for pain without an anatomical reason may lead to gait abnormalities and possible future problems within the spinal and kinetic chain. A complete reference list can be found online at ExpertConsult.com.
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REFERENCES 1. Al-Kaisy A, Van Buyten JP, Smet I, et al. Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study. Pain Med. 2014;15(3):347–354. 2. Bigos SJ, Holland J, Holland C, et al. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J. 2009;9(2):147–168. 3. Brown T, Norton PL. The immobilizing efficiency of back braces; their effect on the posture and motion of the lumbosacral spine. J Bone Joint Surg Am. 1957;39-A(1):111–139. 4. Brumagne S, Cordo P, Lysens R, et al. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine. 2000;25(8):989–994. 5. Calmels P, Queneau P, Hamonet C, et al. Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine. 2009;34(3):215–220. 6. Camara R, Ajayi OO, Asgarzadie F. Are external cervical orthoses necessary after anterior cervical discectomy and fusion: a review of the literature. Cureus. 2016;8(7):e688. 7. Campbell MJ, Carreon LY, Traynelis V, et al. Use of cervical collar after single-level anterior cervical fusion with plate: is it necessary? Spine. 2009;34(1):43–48. 8. Cholewicki J, Shah KR, McGill KC. The effects of a 3-week use of lumbosacral orthoses on proprioception in the lumbar spine. J Orthop Sports Phys Ther. 2006;36(4):225–231. 9. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. 10. Cooper G. Lower back pain: an overview of the most common causes. In: Non-Operative Treatment of the Lumbar Spine. Springer; 2015:11–13. 11. Coxhead CE, Inskip H, Meade TW, et al. Multicentre trial of physiotherapy in the management of sciatic symptoms. Lancet. 1981;1(8229):1065–1068. 12. Cusin E, Do MC, Rougier PR. How does wearing a lumbar orthosis interfere with gait initiation? Ergonomics. 2016;1–7. 13. Dailey AT, Ghogawala Z, Choudhri TF, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14: brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine. 2014;21(1):91–101. 14. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31(23): 2724–2727. 15. Dillane JB, Fry J, Kalton G. Acute back syndrome—a study from general practice. Br Med J. 1966;2(5505):82–84. 16. Dionyssiotis Y, Trovas G, Thoma S, et al. Prospective study of spinal orthoses in women. Prosthet Orthot Int. 2015;39(6):487–495. 17. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377–384. 18. Eisinger DB, Kumar R, Woodrow R. Effect of lumbar orthotics on trunk muscle strength. Am J Phys Med Rehabil. 1996;75(3):194–197. 19. Fayolle-Minon I, Calmels P. Effect of wearing a lumbar orthosis on trunk muscles: study of the muscle strength after 21 days of use on healthy subjects. Joint Bone Spine. 2008;75(1):58–63. 20. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251–258. 21. Gill KP, Callaghan MJ. The measurement of lumbar proprioception in individuals with and without low back pain. Spine. 1998;23(3):371–377. 22. Gore M, Sadosky A, Stacey BR, et al. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine. 2012;37(11):E668–E677. 23. Holla M, Huisman JM, Hosman AJ. A validated classification for external immobilization of the cervical spine. Evid Based Spine Care J. 2013;4(2):72–77.
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24. Holla M, Huisman JM, Verdonschot N, et al. The ability of external immobilizers to restrict movement of the cervical spine: a systematic review. Eur Spine J. 2016;25(7):2023–2036. 25. Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine. 2002;27(11):1142–1148. 26. Hsieh CY, Phillips RB, Adams AH, et al. Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther. 1992;15(1):4–9. 27. Karimi MT, Kamali M, Fatoye F. Evaluation of the efficiency of cervical orthoses on cervical fracture: a review of literature. J Craniovertebr Junction Spine. 2016;7(1):13–19. 28. Kawaguchi Y, Gejo R, Kanamori M, et al. Quantitative analysis of the effect of lumbar orthosis on trunk muscle strength and muscle activity in normal subjects. J Orthop Sci. 2002;7(4):483–489. 29. Kawchuk GN, Edgecombe TL, Wong AY, et al. A non-randomized clinical trial to assess the impact of nonrigid, inelastic corsets on spine function in low back pain participants and asymptomatic controls. Spine J. 2015;15(10):2222–2227. 30. Koes B, Van Den Hoogen H. Efficacy of bed rest and orthoses of low-back pain: a review of randomized clinical trials. Eur J Phys Med Rehabil. 1994;4(3):86–93. 31. Lanhers C, Boutevillain L, Pereira B, et al. Lumbar support and nonspecific low back pain: evidence for daily practice. Ann Phys Rehabil Med. 2016;59S:e29. 32. Lee AS, Cholewicki J, Reeves NP, et al. Comparison of trunk proprioception between patients with low back pain and healthy controls. Arch Phys Med Rehabil. 2010;91(9):1327–1331. 33. McNair PJ, Heine PJ. Trunk proprioception: enhancement through lumbar bracing. Arch Phys Med Rehabil. 1999;80(1):96–99. 34. Million R, Nilsen KH, Jayson MI, et al. Evaluation of low back pain and assessment of lumbar corsets with and without back supports. Ann Rheum Dis. 1981;40(5):449–454. 35. Morrisette DC, Cholewicki J, Logan S, et al. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine. 2014;39(21):1733–1742. 36. Morrison S, Russell DM, Kelleran K, et al. Bracing of the trunk and neck has a differential effect on head control during gait. J Neurophysiol. 2015;114(3):1773–1783. 37. Nachemson A, Morris JM. In vivo measurements of intradiscal pressure. discometry, a method for the determination of pressure in the lower lumbar discs. J Bone Joint Surg Am. 1964;46:1077–1092. 38. Newman M, Minns Lowe C, Barker K. Spinal orthoses for vertebral osteoporosis and osteoporotic vertebral fracture: A systematic review. Arch Phys Med Rehabil. 2016;97(6):1013–1025. 39. Phaner V, Fayolle-Minon I, Lequang B, et al. Are there indications (other than scoliosis) for rigid orthopaedic brace treatment in chronic, mechanical low back pain? Ann Phys Rehabil Med. 2009;52(5):382–393. 40. Pope MH, Phillips RB, Haugh LD, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine. 1994;19(22):2571–2577. 41. Radebold A, Cholewicki J, Polzhofer GK, et al. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine. 2001;26(7):724–730. 42. Reyna JR Jr, Leggett SH, Kenney K, et al. The effect of lumbar belts on isolated lumbar muscle. Strength and dynamic capacity. Spine. 1995;20(1):68–73. 43. Roelofs PD, Bierma-Zeinstra SM, van Poppel MN, et al. Cost-effectiveness of lumbar supports for home care workers with recurrent low back pain: an economic evaluation alongside a randomized-controlled trial. Spine. 2010;35(26):E1619–E1626. 44. Roelofs PD, van Poppel MN, Bierma-Zeinstra SM, et al. Determinants of the intention for using a lumbar support among home care workers with recurrent low back pain. Eur Spine J. 2010;19(9):1502–1507.
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45. Russell DM, Kelleran KJ, Morrison S. Bracing the trunk and neck in young adults leads to a more aged-like gait. Gait Posture. 2016;49:388–393. 46. Rzewuska M, Ferreira M, McLachlan AJ, et al. The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis. Eur Spine J. 2015;24(4):702–714. 47. Seo HJ, Kim KU. Quality assessment of systematic reviews or metaanalyses of nursing interventions conducted by Korean reviewers. BMC Med Res Method. 2012;12:129. 48. Smith GE. The most ancient splints. Br Med J. 1908;1(2465):732–736, 732. 49. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: A systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208. 50. Terai T, Yamada H, Asano K, et al. Effectiveness of three types of lumbar orthosis for restricting extension motion. Eur J Orthop Surg Traumatol. 2014;24(suppl 1):S239–S243. 51. Valentin GH, Pedersen LN, Maribo T. Wearing an active spinal orthosis improves back extensor strength in women with osteoporotic vertebral fractures. Prosthet Orthot Int. 2014;38(3):232–238. 52. Valle-Jones JC, Walsh H, O’Hara J, et al. Controlled trial of a back support (‘Lumbotrain’) in patients with non-specific low back pain. Curr Med Res Op. 1992;12(9):604–613.
53. van den Hoogen HJ, Koes BW, van Eijk JT, et al. On the course of low back pain in general practice: a one year follow up study. Ann Rheum Dis. 1998;57(1):13–19. 54. van Duijvenbode IC, Jellema P, van Poppel MN, et al. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008;(2):CD001823. 55. van Poppel MN, de Looze MP, Koes BW, et al. Mechanisms of action of lumbar supports: a systematic review. Spine. 2000;25(16):2103–2113. 56. Vasiliadis ES, Grivas TB, Kaspiris A. Historical overview of spinal deformities in ancient Greece. Scoliosis. 2009;4:6. 57. Von Korff M. Studying the natural history of back pain. Spine. 1994;19(18):2041S–2046S. 58. Wahlgren DR, Atkinson JH, Epping-Jordan JE, et al. One-year follow-up of first onset low back pain. Pain. 1997;73(2):213–221. 59. Walsh NE, Schwartz RK. The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace. Am J Phys Med Rehabil. 1990;69(5):245–250. 60. Werber A, Schiltenwolf M. Treatment of lower back pain—the gap between guideline-based treatment and medical care reality. Healthcare. 2016;4(3). 61. Wood KB, Buttermann GR, Phukan R, et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: a prospective randomized study with follow-up at sixteen to twenty-two years. J Bone Joint Surg Am. 2015;97(1):3–9.