脊椎輔具

2010/5/26
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Orthoses
希臘文” Orthos”:making straight
 中文:輔具
 英文:

◦ Orthotics: the application of exoskeletal
devices
◦ Orthosis: exoskeletal devices

定義:(ISP&O)
 External applied device
 Modify structural & functional NM skeletal system

範圍: 上肢、下肢、脊柱
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Orthoses Benefits

功用(Benefits)
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協助肌力不足動作(Support)
矯正變形肢體(Align or correct)
預防進一步傷害(Prevent)
減輕疼痛(Relieve pain)
協助術後固定以促進癒合(Promote healing)
改善肢體功能(Improve function)
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Orthoses Drawbacks
皮膚不易清潔:黴菌感染、濕疹
 壓瘡

 壓力分布不均
 穿戴方式不良
 皮膚感覺受損
脊椎旁肌肉萎縮
 關節活動度減少
 任意運動脊椎
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脊椎輔具
減輕患者不適
 矯正不正常脊柱曲度
 保持脊柱穩定度
 限制某些運動
 預防進一步神經傷害
 協助脊椎術後固定以促進癒合
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 3-point principle
◦ 支點:上下兩點
◦ 施力點:中間
◦ 施力臂(lever arm)要長，接觸面要大

Total contact molded system
◦ 石膏取模
◦ 接觸面積延伸全部軀體
◦ 壓力分布平均
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處方脊椎輔具
考慮須限制的脊椎運動方向
 輕重
 價格
 耐用性
 舒適性
 有效性
 穿戴時間與注意事項
 輔具材質

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Subgroups of Spine for Orthoses
Upper cervical(C1-C2)
 Mid-cervical (C3-T1)
 Thoracic(T2-T10)
 Thoracolumbar(T11-L1)
 Lumbar(L1-L4)
 Lumbosacral(L4-S1)

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Subgroups of Spinal Orthoses
Cervical orthoses (CO)
 Head cervical orthoses(HCO)
 Cervical thoracic orthoses(CTO)
 Cervical thoracic lumbar sacral
orthoses(CTLSO)
 Thoracolumbosacral orthoses(TLSO)
 Lumbosacral orthoses(LSO)
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Cervical spine
Seven vertebrae
Cervical motion
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Flexion-extension(C5-C6 ＞C6-C7 ＞C4C5)
Lateral bending(C2-C6)
Rotation(C1-C2)
The most mobile
The smallest skin surface
Vital structures within this small area
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Cervical Orthoses
Collar(soft collar, rigid collar)
 Head Cervical Orthoses
 Cervicothoracic orthoses
 Halo devices
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Collars

Soft collars
◦ Foam rubber
◦ Restriction
 3% flexion
 26% extension
 17% rotation
◦ Warmth & comfort
◦ Reminder
◦ Support
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Collars

Rigid collars
◦ Polyethylene band
◦ Restriction
 70% flexion- extension
 30% lateral bending
 50% rotation
◦ Discomfort
◦ 持續配戴仍有3-25%傷害
◦ 追蹤及衛教
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Head Cervical Orthosis
Additional support occiput
to chin
 Stiffneck collar

◦ Prehospital immobilization
◦ Mandible,Occiput >32mmHg

Philadelphia collar
◦ Restriction
 71% flexion- extension
 34% lateral bending
 66% rotation
Miami, Newport…
 Indication: stable midcervical injury

Stiffneck collar
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Head Cervical Orthosis
Miami collar
Philadelphia collar
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Cervical Thoracic Orthoses
Provide restriction in mid to lower Cspine
 Yale cervicothoracic orthoses &
Philadelphia Halo
 Poster design
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◦ 4-poster orthses
◦ 2-poster orthses
◦ SOMI(sterno-occipital-mandibular
immobilizer)
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Yale Orthoses
An extended
Philadelphia collar
 Continueing down the
thorax anteriorly &
posteriorly
 A strap for a higher
occipital support
 More restriction in
flexion-extension &
rotation
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Poster brace

4-poster orthoses

Bilateral mandibuar and
occipital supports
◦ Struts attaching to
thoracic plates
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Poster brace

2-poster brace (Guilford brace)
◦ Chin & occipital supports by anterior and posterior
struts
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SOMI
Named for attachment
3 aluminum bars(2 from
the occipital & 1 from
the mandibular) to the
anterior sternal chest
plate
 Don & doff during lying
 Restriction
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◦ 76% flexion- extension
◦ 50% lateral bending
◦ 68% rotation
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Halo
Most restrictive
 Attached with fixation pins into the skull
 C1-C2 stable fracture
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Restriction
◦ 96% flexion- extension
◦ 92% lateral bending
◦ 97% rotation
 Snaking phenomenon
 Avoiding shoulder shrugging & abduction >90
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Halo
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Complication
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Pin loosening
Infection
Pin discomfort
Pressure sores
Scars
Skull perforation
Limitaion of activities
Local wound care by Saline twice per day
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Halo
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TMBJ
Thermoplastic Minerva
body jacket
 Newer designs of
Minerva
 Extends to the similar
level of halo vest
 Excellent restriction
 Comfort
 No invasive pins
 Preschool children
 Offer similar halo
support below C2
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Thoracic & Lumbosacral Spine

Control systems: three-point pressure
◦ Trunk support
◦ Restrict Motion
◦ Anterior abdominal compression
 Straighten lumbar lordosis
 Decreases IV joint motion
 Decrease the load on the vertebrae and discs
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Thoracic & Lumbosacral Orthoses

Stabilization
◦ Material
◦ Encompass spinal segment

Impact function
◦ ↑energy consumption
◦ ↓respiratory function
◦ ↓cadence & stride length
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Thoracolumbosacral Orthoses
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Classification
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Corsets, belt, binder
Rigid brace:chairback brace, Knight-Taylor
Custom-molded body jacket:Boston, Aspen
Hyperextension brace:Jewett,CASH
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Trochanteric Belt
Encircles the pelvis
 Canvas or leather
 2-3 inches
 Healing pelvic fx & SI pain
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Sacral Belt
Iliac crest-pubic symphisis
 Gluteal fold
 4-6 inches
 Postpartum & SI joint pain
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Corsets
Sacroiliac Corsets
 Lumbar and lumbosacral Corsets
 Thoracolumbar Corsets
 Indication
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◦ Low back pain
◦ Postpartum
◦ Posttraumatic stabilization
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Sacroiliac Corsets
Lumbosacral Corsets
Thoracolumbar
Corsets
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Corsets
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Function
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Less restrict motion
↑abdominal pressure
Stabilize the pelvic joints
Reminds to maintain proper posture
Disadvantage
◦ Weakening the muscles of trunk support
◦ Instruct proper exercise
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Thoracolumbosacral Orthoses
Protect thoracic and lumbar spine below
T6
 Classification
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Corsets, belt, binder
Rigid brace:chairback brace, Knight-Taylor
Custom-molded body jacket:Boston, Aspen
Hyperextension brace:Jewett,CASH
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Knight-Taylor brace (Taylor brace)
TLS flexion-extension control orthosis
 Limits thoracic motion
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◦ Axillary straps are tightened
◦ Ineffective if straps are loose
Stable pathologiic fx
 Postsurgical stable T-L fracture
 Kyphosis
 Severe muscle strain
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Knight-Taylor brace (Taylor brace)
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Thoracic band
Pelvic band
Posterior paraspinal uprights
Lateral bars
Mid-thoracic transverse bar
Abdominal apron
Interscapular band
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Molded Spinal Orthoses
Total contact CTLSO, TLSO, LSO
 More comfortable, expensive
 Stable compression fracture, post-op
 Three-point pressure design
 Boston type, Aspen type, CAMP type
 Restriction 70% motion in all plane
 Decrease 50 % lever arm
 Limitation of L4-5
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Molded Spinal Orthoses
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Hyperextension Brace
TLS Flexion Control Orthosis
 Anterior compression fracture of VB
 Avoid flexion and kyphosis deterioration
 No abdominal support
 3-point: sternum,pelvis,upper lumbar
spine
 Contraindication: osteoporosis,

posterior element instability or fracture, arthritis
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Hyperextension Brace

Jewett brace
Jewett brace
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CASH brace( cruciform anterior spinal
hyperextension brace)
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•
•
•
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Limits flexion / extension T6 - T10
not limit lateral bending
aluminum and polyethylene
Anterior cross with posterior pad
Hinged sternal, pectoral, pubic pads
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Indications:
Kyphosis in Osteoporosis
Thoracic vertebral body fractures
(anterior compression fractures )
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CASH brace
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Lumbosacral Orthoses
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Classification
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Corsets(binder)
Rigid brace:Chairback brace, Knight orthosis
Custom-molded body jacket:Boston brace
Hyperflexion brace:William’s orthosis
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Chairback brace
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LS flexion-extension control orthosis
Thoracic band(Sternal pad)
Pelvic band
2 LS paraspinal uprightsI
Abdominal support ↓
Restriction:Flexion, extension,
lateral rotation (45%)
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Knight Brace
LS flexion-extension control orthosis
 Added lateral bars
 Indication:
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◦ Low back pain
◦ Disc herniation
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A useful prognostic aid for spinal fusion
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Hyperflexion Brace
LS extension control orthosis
 William’s orthosis
 Short, dynamic orthosis
 Indication:
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Over lordosis curve
Facet joint arthritis
Spondylolisthesis
Muscle strain
Contraindication:
◦ Anterior compression fracture
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Thoracolumbar Fracture
No orthosis totally immobilize TL spine
Instruction of activity restriction
High level fracture(T1-T6): no consensus
Low level fracture(below T6):body jacket or
Jewett brace
 VB compression fracture without neurologic
impairment-thoracoabdominal support
 Fracture with posterior element involvement
 Spine metastasis:
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◦ Without instability:TLSO corset with rigid stay
◦ With neurologic deficits:body jacket
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Thoracolumbar Fracture

A brace after surgery depends on
◦ The type of fracture
◦ Surgical procedure/stabilization
Avoidance of excessive bending & heavy
lifting continue for 3 months
 Rehabilitaion program: transfer, ambulaton, ADL
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ORTHOSES FOR
SCOLIOSIS
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Scoliosis/Kyphosis
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Scoliosis: a lateral curve
◦ Age: infantile, juvenile, adolescence,or adult
◦ Cause: congenital, degenerative,
idiopathic(Juvenile)
◦ Cobb angle; Risser’s sign(growth plate)

Kyphosis: a sagittal or backward curve
(T level >20-40)
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Rehabilitaion
◦ Exercise(spine extension X’s,pelvic tilt)
◦ Bracing
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Scoliosis bracing

Bracing or operation?
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骨骼發育情形

Bracing:

Operation:
◦ 單弧或雙弧，立體型式，旋轉，角度
◦ 角度進展速度
◦ 角度>20度且骨骼發育未成熟或年進展> 5度
◦ 角度>30度
◦ 適當輔具、足夠穿戴時間、穿到骨骼發育成熟
◦ 角度>40度
◦ 角度>30度且伴隨明顯旋轉
◦ 雙弧>30度
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Scoliosis bracing
CTLSO：apex above T8
 TLSO:apex below T9
 LSO: lumbar scoliosis
 Stimulate active corrective forces
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Milwaukee: 優於被動性限制輔具
輔具下端固定於骨盆
彎曲弧度頂點加塑膠片(軀幹壓力)
須具正常肌力、皮膚感覺、本體覺
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Scoliosis bracing

順從性:
◦ 好發青少年，穿戴輔具對外觀心理產生負
面影響，許多研究顯示病人穿戴時間不足

穿戴時間:
◦ 沒有定論，理想應穿戴一天23小時，只有
清潔拿下，穿到青春期結束，骨骼完全成
熟為止
◦ 穿戴時間和效果成正比，穿戴時間不足，
會顯著降低輔具效果
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Scoliosis bracing
Milwaukee CTLSO brace
TLSO-body jacket Boston brace
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ORTHOSES OF LOW
BACK PAIN
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Low Back Pain
Etiology
 Diagnosis
 Treatment
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Medication
Physical modality
Operation
Orthosis
Exercise
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Low Back Pain
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Core muscles
Quadratus lumbarum
Int oblique
(local stability muscle)
umbilicus內吸
穩定脊椎
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Core muscles

Local stability muscle
◦ Umbilicus 內吸
◦ 提供各脊椎椎體間穩定力
◦ 脊椎維持正中區域

Global stability muscle
◦ 控制脊椎動作方向
◦ 較大動作力矩
◦ 對抗平衡衝擊於脊椎動作外力
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Core muscles strengthening
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腹部、背部、臀部肌群
搭配徒手或器械
動作控制及身心靈平衡
功能性訓練
彼拉提斯(1880-1967)
低衝擊性肌耐力、伸展運動
◦ 熱身運動
◦ 主要運動
◦ 緩和運動
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Core Muscles
融合腹式與胸式呼吸
法
• 吸氣橫膈下降
•
◦ 活動胸廓，增加肺活量
◦ 增加腹腔壓力
深層核心肌群收縮
• 增加脊椎穩定
•
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Orthoses of Low Back Pain

Function:
◦
◦
◦
◦
Restriction motion
Heat or massagelike effect
Trunk support
Psychological support
Check in sitting and standing position
 Check signs of irritation(disappear in 10
min)
 Check weight, comfort,function,
appearance

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脊椎輔具
輔具適應症、輔具選擇、副作用
 骨骼排列、肌力、神經學異常
 衛教:為何穿、穿多久、穿到何時
 正確穿戴輔具以及病人順從性是決定輔
具效果關鍵
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