The collarbone orthosis helps to correct the kyphosis

Background: Orthoses are external aids that are often used to treat pain and conditions in the spine, such as lumbago, whiplash or herniated discs. The aim of this review article is to evaluate the effectiveness and complications of orthosis treatment in typical clinical pictures and after operations on the spine. The orthotic treatment of fractures and deformities should not be evaluated here.

Methods: It is a review article based on a selective literature search in the Medline database, taking into account controlled studies, systematic reviews and recommendations of the professional associations.

Results: A total of three systematic reviews and four controlled studies could be identified. So far, there are only very few controlled studies that compare the effectiveness of orthosis treatment with other conservative therapy modalities and surgical therapy. No sufficient evidence could be found for the use of orthoses postoperatively, for lumbar radiculopathy and for whiplash injuries to the cervical spine. One study showed that short-term immobilization is effective for cervical radiculopathy. Orthosis treatment is not recommended for non-specific low back pain. Possible complications with cervical orthotics are pressure damage to the skin and dysphagia with cervical orthotics.

Conclusions: Since there is not yet sufficient evidence for the use of orthoses after interventions on the spine and in painful conditions in the cervical and lumbar spine, they should only be used after individual examination of the indication.

Orthoses are medical devices that are prescription aids in Germany (1). In the list of aids, they are defined as aids that secure their function, that enclose the body or that fit the body. One or more of the following effects should be achieved constructively through physical or mechanical properties: stabilize, immobilize, mobilize, relieve, correct, retain, fix, reduce and replace failed body functions (1). In addition to the made-to-measure orthotics, ready-made and prefabricated orthotics, which are adapted in a modular system, are available. The bandages, which are only made of elastic or solid textile materials, are closely linked to the orthotics. Pads can be incorporated into the back of bandages and orthotics. These are supposed to have a compressing and massaging effect on the soft tissues in order to release tension in the muscles and reduce pain.

Due to the high prevalence of spinal diseases, orthoses are often prescribed in everyday clinical practice. About 3–7% of the population suffers from chronic lumbago (2). For this reason, lumbar orthoses and bandages in particular are used for therapy as well as primary and secondary prevention (3). A systematic survey of the frequency of prescriptions for spinal orthoses and supports has not yet taken place. An inquiry at the Barmer Ersatzkasse showed that the number of reimbursed orthoses and supports increased by 45% to 97,425 in 2011 (2009: 67,211 and 2010: 72,633; personal communication, Barmer press office of June 25, 2012). As a result, the question arises for which indications on the spine evidence of the effectiveness of orthotics and bandages has been proven.

In this overview, the biomechanical fundamentals of treatment with orthoses and bandages on the spine should first be presented. This is followed by an overview of the clinical results from controlled clinical studies and reviews in order to give recommendations for the indication of orthosis therapy for the most common acute and chronic diseases of the cervical and lumbar spine. Due to the scope, the orthotic treatments of deformities (scolioses; kyphosis), fractures, spinal tumors at risk of fracture and the thoracic spine are not presented in this review article.

Biomechanical aspects

The desired goals of an orthotic treatment are to correct an existing deformity or to avoid progression using the three-point principle (two mostly in the same direction counteract a support), stabilization and immobilization of weak or damaged spinal segments, and a reduction in the axial load absorption of affected spinal segments and a control of the movement (4, 5). Depending on the indication, various functional aspects of an orthosis are emphasized. Secondary effects of the orthotic treatment that are postulated are a massage of the soft tissues, a warming and a placebo effect (5). The orthosis is intended to warn the patient to prevent excessive mobility and to improve posture through tactile stimuli (6). The orthosis should support the patient in fulfilling the occupational therapy requirements or should at least help to slow down the sequence of movements (4).

Another hypothesis is an increase in intra-abdominal pressure, which should lead to a reduction in the effort required by the lumbar muscles when straightening up (6). The hypothesis that this reduces the stress on the muscles and the axial stress on the lumbar spine could not be proven in a systematic review (6, 7). Both soft and rigid lumbar orthoses have been shown to significantly limit the movement of flexion-extension and lateral flexion. A significant reduction in rotation, which is also considered a risk factor for back pain, could not be demonstrated (6). Due to the sometimes contradicting results of biomechanical studies, no final assessment of the mechanism of action of the orthoses can be made at this point in time (6).

Soft cervical bandages (Figure 1a) and fixed orthoses (Figure 1b) are used on the cervical spine. As expected, the soft cervical bandages have little influence on the mobility of the cervical spine (4).

The immobilization of the cervical spine is difficult due to the small contact areas of the orthosis on the occiput, the mandible and the clavicle as well as the limited possibility of compression of the cervical soft tissues. As a result, there is a certain mobility of the cervical spine during the chewing process and when moving the shoulder (8). A firm Philadelphia tie still allows considerable residual mobility of 29% for flexion and extension, 44% for rotation and 66% for side bending (4).

Clinical indications

Whiplash

In Germany, around 200,000 acceleration injuries to the cervical spine are to be expected every year (9). Neck pain (88–100%) and headache (54–66%) can be identified as the main clinical symptoms (9). A soft cervical bandage is often prescribed after a bony injury has been ruled out. In a systematic review, the effectiveness of various conservative therapy modalities was measured in terms of the primary parameters pain, the global effect and participation in activities of daily living (9). In five of the eleven included studies, immobilization with cervical bandages was compared to an active-mobilizing therapy regimen (9). Mobilization was superior to immobilization in four studies (10–13). No difference was found in one study (14). Due to the poor methodological quality of the included studies, the authors of the systematic review concluded that active intervention tends to be more effective than immobilization.

Cervical Radiculopathy

Cervical radiculopathy often arises from degenerative processes (e.g. herniated disc, spondylarthrosis) and is characterized by neck pain with dermatom-related radiation to the upper extremity. In the case of acute symptoms and no indication for surgery (no higher-grade paresis), a conservative attempt at therapy with analgesics and immobilization or physiotherapy is always undertaken. A positive effect is seen within 3–6 months in 80–90% of patients (15, 16).

In a three-arm prospective randomized study (RCT), immobilization using a semi-rigid orthosis, physiotherapy and the use of analgesics alone was compared in patients with an acutely occurring and neurologically confirmed cervical radiculopathy (n = 207, duration of complaint < 1 monat, vas="" und="" neck-disability-index)="" (17).="" nach="" sechs="" wochen="" war="" eine="" überlegenheit="" der="" ruhigstellung="" mit="" einer="" semi-rigiden="" orthese="" und="" der="" physiotherapie="" (zweimal="" pro="" woche)="" gegenüber="" alleiniger="" einnahme="" von="" analgetika="" festzustellen.="" nach="" sechs="" monaten="" zeigten="" sich="" zwischen="" den="" gruppen="" keine="" signifikanten="" unterschiede.="" die="" autoren="" empfahlen="" eine="" ruhigstellung="" aufgrund="" der="" niedrigeren="" kosten="" im="" vergleich="" zur="" physiotherapie.="" außer="" dieser="" studie="" existieren="" keine="" hochwertigen="" studien="" zur="" bewertung="" der="" immobilisation="" im="" vergleich="" zu="" anderen="" konservativen="" therapieformen.="" die="" frage,="" ob="" auch="" patienten="" mit="" akuten="" zervikobrachialgien="" ohne="" neurologische="" einschränkungen="" von="" einer="" ruhigstellung="" profitieren,="" ist="" weiterhin="">

In patients with chronic radiculopathy (more than three months, median 21 months) Persson et al. In a three-armed RCT after four months, we found that surgical therapy was superior to physiotherapy and treatment with a rigid orthosis (three months of wearing) based on pain and neurological deficits (18). There were no significant differences between the conservative treatment arms after four months and between all treatment groups after one year.

Acute and chronic lumbago

Lumbar and lumbosacral orthoses are often used for the treatment of acute and chronic pain conditions as well as for prevention. The primary treatment goals are faster mobilization and improvement of the symptoms. A Cochrane Review from 2001 on the use of lumbar orthoses and supports for the prevention and treatment of lumbago analyzed 13 controlled studies (5). Only four studies were of good methodological quality. Often there was a lack of information on the orthosis used and the patient's compliance. The authors found that there is no strong evidence (level 1) that speaks for or against the effectiveness of lumbar orthoses in the prevention or treatment of lumbago. Moderate evidence (level 2) speaks against the effectiveness of the lumbar orthoses in primary prevention. So far there is no evidence for secondary prevention (grade 4). The studies show controversial results for the effectiveness of therapy for the lumbago. A low level of evidence (grade 3) suggests that some rigid orthoses are more effective than bandages. Overall, the authors of the review come to the conclusion that lumbar orthoses are not suitable for primary prevention and for the treatment of lumbar back pain. In the current Cochrane Review from 2008, the authors came to a similar conclusion and concluded that further high-quality randomized controlled studies were necessary to assess the effectiveness of the orthoses (19).

The National Care Guideline for Low Back Pain (20) recommends not using orthoses for the treatment of acute or chronic non-specific low back pain (recommendation grade A). For this recommendation, data from ten of a total of 54 identified studies were assessed in an evidence analysis. Of these, four studies with moderate and one study with good methodological quality could not show any positive effectiveness of the orthoses, either in comparison with other non-drug treatment methods or in comparison with no intervention. Five studies that demonstrated a positive effect of the orthotics were of moderate methodological quality, so that the studies with a negative result were rated higher.

Spondylodiscitis

Another indication for orthosis treatment is conservative therapy for spondylodiscitis if there are no severe vertebral body destruction and no urgent indication for surgery (21). In the thoracolumbar and lumbar regions, a sturdy, made-to-measure polyethylene corset can immobilize the affected spinal column segments and relieve the anterior spinal column segments by reclining (22). Together with antibiotic therapy, most authors recommend treatment with a fixed brace for 6–10 weeks (23, 24).

Cervical spondylodiscitis is often treated surgically. If the patient is eligible for conservative therapy, immobilization with a rigid orthosis is recommended (21).

There are currently no data from controlled studies on the rare and heterogeneous spondylodiscitis.

Postoperative orthotic treatment

In an international questionnaire study, 61% of spine surgeons answered that they prescribe an orthosis for a period of one to eight weeks for operations on the cervical spine and 49% that they prescribe an orthosis for operations on the lumbar spine (25). The main reason given was a restriction in patient activity due to orthosis treatment.

So far, there are no data from controlled studies on the effectiveness of orthoses after stability-maintaining interventions such as decompression and disc operations on the lumbar spine. There is also no consensus on the necessary rigidity of the orthosis, the type of orthosis and the duration of treatment. At the surgeon's discretion, a bridging girdle according to Hohmann (Figure 2) (4) is prescribed for the first six weeks postoperatively in our clinic after multi-segment decompressions and in the event of impending instability.

In lumbar spondylodesis with angle-stable screw-rod instrumentation, fusion rates between 46% and 100% can be achieved after two years, depending on the underlying disease (26). The use of orthoses is a controversial issue here (27).

In an RCT, the value of postoperative corset treatment after lumbar spinal fusion with a posterior screw-rod system and autologous iliac crest chipping in degenerative diseases of the lumbar spine was examined (28). The patients in the intervention group (n = 46) were asked to wear a sturdy corset made to measure for a period of eight weeks postoperatively for 24 hours (except for personal hygiene and during examinations) and then to exercise for a further four weeks. The patients in the control group (n = 44) were mobilized without an orthosis. After a period of two years, there were no significant differences between the two groups in the measured clinical parameters (Dallas Pain Questionnaire and SF-36), in the rate of postoperative complications and revisions. This study found no advantage or disadvantage to using a brace after lumbar spinal fusion.

The frequent postoperative use of orthoses on the cervical spine can possibly be explained by the high mobility of this spine section and the frequent use of fusing surgical techniques. Fusions are mostly performed without plate osteosynthesis using intervertebral implants. The orthosis is intended to reduce mobility and the load on the operated segment and consequently improve the rate of fusion. With the use of modern alloplastic cages made of plastic (polyetheretherketone) or titanium instead of bone material as an intervertebral placeholder, the need for postoperative immobilization in the absence of evidence is questionable. In a prospective, randomized pilot study, patients benefited from immobilization in the first six weeks after fusion with an intervertebral cage, measured by the neck disability index and pain reduction (29).

A multicenter RCT with a follow-up period of 24 months came to the conclusion that a cervical orthosis is not necessary after a monosegmental anterior fusion with plate fixation (30). The cervical brace did not improve the clinical result, as measured by the Neck Disability Index, the SF-36, or the Numerical Rating Scale (NRS), or the radiological fusion rate.

Complications of orthotic treatment

The attending physician and the patient often have concerns that long-term wear of an orthosis weakens the muscles that stabilize the trunk. Studies on this have shown controversial data, some of which show a strengthening of the muscles (31, 32), a decrease in strength (33) or no differences (34). A study of isokinetic and isometric strength in healthy volunteers showed no significant differences after using a lumbar bandage for 21 days (35).

Excessive pressure of the orthosis on the skin and exposed anatomical structures can cause ulcers. Therefore, the use of orthoses should be limited to patients who perceive the corresponding pain stimuli and can react to them adequately.

Depending on how long rigid cervical orthoses are worn, pressure ulcers on the mandible and occiput can occur in 6.8% of patients (36, 37). Cervical orthoses can trigger dysphagia through narrowing of the pharynx, changes in the act of swallowing (38) and the unusually upright posture of the head when eating.

It is therefore generally recommended that orthosis treatment should be prescribed and monitored by a doctor. The aim is for the duration of treatment to be as short as possible and for the patient to be mobilized as early as possible.

Conflict of interest

Dr. Zarghooni and Prof. Eysel received funding for a research project they initiated from Bauerfeind AG in Zeulenroda-Triebes.

Dr. Beyer and Dr. They declare that they have no conflict of interest.

Manuscript dates
submitted: November 26, 2012, revised version accepted: August 12, 2013

Address for the authors
Dr. med. Kourosh Zarghooni
Clinic and polyclinic for orthopedics and trauma surgery
University Hospital Cologne
Kerpener Strasse 62
50937 Cologne
[email protected]

Citation style
Zarghooni K, Beyer F, Siewe J, Eysel P: The orthotic treatment of acute and chronic disease of the cervical and lumbar spine. Dtsch Arztebl Int 2013; 110 (44): 737-42. DOI: 10.3238 / arztebl.2013.0737

@ The German version of this article is available online:
www.aerzteblatt-international.de

Top Association G: List of Aids 2012 Available from: https://hilfsmittel.gkv-spitzenverband.de/home.action. Last accessed on 26 November 2012.
Anderson G: The epidemiology of spinal disorders. In: Frymeyer JW (ed.): The adult spine: principle and practice. 2nd ed; Lippincott-Raven Publishers: Philadelphia 1997; 93-141. MEDLINE
Dillingham TR: Lumbar supports for prevention of low back pain in the workplace. JAMA 1998; 279: 1826-8. CrossRefMEDLINE
Agabegi SS, Asghar FA, Herkowitz HN: Spinal orthoses. J Am Acad Orthop Surg 2010; 18: 657-67. MEDLINE
Jellema P, van Tulder MW, van Poppel MN, Nachemson AL, Bouter LM: Lumbar supports for prevention and treatment of low back pain: A systematic review within the framework of the cochrane back review group. Spine (Phila Pa 1976) 2001; 26: 377-86. CrossRefMEDLINE
van Poppel MN, de Looze MP, Koes BW, Smid T, Bouter LM; Mechanisms of action of lumbar supports: A systematic review. Spine (Phila Pa 1976) 2000; 25: 2103-13. CrossRefMEDLINE
Perkins MS, Bloswick DS: The use of back belts to increase intraabdominal pressure as a means of preventing low back injuries: A survey of the literature. Int J Occup Environ Health 1995; 1: 326-35. MEDLINE
Chin KR, Auerbach JD, Adams SB, Sodl JF, Riew KD: Mastication causing segmental spinal motion in common cervical orthoses. Spine (Phila Pa 1976) 2006; 31: 430-4. CrossRefMEDLINE
Peeters GG, Verhagen AP, de Bie RA, Oostendorp RA: The efficacy of conservative treatment in patients with whiplash injury: A systematic review of clinical trials. Spine (Phila Pa 1976) 2001; 26: e64-73.
Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I: Acute treatment of whiplash neck sprain injuries.
A randomized trial of treatment during the first 14 days after a car accident. Spine (Phila Pa 1976) 1998; 23: 25-31.
Giebel GD, Edelmann M, Huser R: The distortion of the cervical spine: early functional vs. immobilization treatment [Sprain of the cervical spine: early functional vs. immobilization treatment]. Zentralbl Chir 1997; 122: 517-21. MEDLINE
McKinney LA: Early mobilization and outcome in acute sprains of the neck. BMJ 1989; 299: 1006-8. CrossRefMEDLINE
Mealy K, Brennan H, Fenelon GC: Early mobilization of acute whiplash injuries. Br Med J (Clin Res Ed) 1986; 292: 656-7. CrossRefMEDLINE
Pennie BH, Agambar LJ: Whiplash injuries. A trial of early management. J Bone Joint Surg Br 1990; 72: 277-9. MEDLINE
Persson LC, Carlsson CA, Carlsson JY: Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine (Phila Pa 1976) 1997; 22: 751-8. CrossRefMEDLINE
Saal JS, Saal, Yurth EF: Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976) 1996; 21: 1877-83. CrossRefMEDLINE
Kuijper B, Tans JT, Beelen A, Nollet F, de Visserc M: Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: Randomized trial. BMJ 2009; 339: b3883. CrossRefMEDLINEPubMed Central
Persson LC, Moritz U, Brandt L, Carlsson CA: Cervical radiculopathy: Pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J 1997; 6: 256-66. CrossRefMEDLINEPubMed Central
van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW: Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev 2008 (2): CD001823. MEDLINE
German Medical Association (BÄK), National Association of Statutory Health Insurance Physicians (KBV), Working Group of Scientific Medical Societies (AWMF): National Care Guideline for Low Back Pain - Long Version. Version 4, 2010. Last revised: August 2013. Available from: www.kreuzschmerz.versorgungsleitlinien.de; last accessed on 9 September 2013.
Sobottke R, Seifert H, Fatkenheuer G, Schmidt M, Gossmann A, Eysel P: Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl Int 2008; 105: 181-7. FULL TEXT
Bettini N, Girardo M, Dema E, Cervellati S: Evaluation of conservative treatment of non specific spondylodiscitis. Eur Spine J 2009; 18: 143-50. CrossRefMEDLINEPubMed Central
Di Martino A, Papapietro N, Lanotte A, Russo F, Vadala G, Denaro V: Spondylodiscitis: Standards of current treatment. Curr Med Res Opin 2012; 28: 689-99. CrossRefMEDLINE
Bible JE, Biswas D, Whang PG, Simpson AK, Rechtine GR, Grauer JN: Postoperative bracing after spine surgery for degenerative conditions: A questionnaire study. Spine J 2009; 9: 309-16. CrossRefMEDLINE
Lee CS, Hwang CJ, Lee DH, Kim YT, Lee HS: Fusion rates of instrumented lumbar spinal arthrodesis according to surgical approach: A systematic review of randomized trials. Clin Orthop Surg 2011; 3: 39-47. CrossRefMEDLINEPubMed Central
Connolly PJ, Grob D: Bracing of patients after fusion for degenerative problems of the lumbar spine-yes or no? Spine (Phila Pa 1976) 1998; 23: 1426-8. MEDLINE
Yee AJ, Yoo JU, Marsolais EB, et al .: Use of a postoperative lumbar corset after lumbar spinal arthrodesis for degenerative conditions of the spine. A prospective randomized trial. J Bone Joint Surg on 2008; 90: 2062-8. CrossRefMEDLINE
Abbott A, Halvorsen M, Dedering A: Is there a need for cervical collar usage post anterior cervical decompression and fusion using interbody cages? A randomized controlled pilot trial. Physiother Theory Pract 2013; 29 (4): 290-300. CrossRefMEDLINE
Campbell MJ, Carreon LY, Traynelis V, Anderson PA: Use of cervical collar after single-level anterior cervical fusion with plate: Is it necessary? Spine (Phila Pa 1976) 2009; 34: 43-8. MEDLINE
Kawaguchi Y, Gejo R, Kanamori M, Kimura T: Quantitative analysis of the effect of lumbar orthosis on trunk muscle strength and muscle activity in normal subjects. J Orthop Sci 2002; 7: 483-9. CrossRefMEDLINE
Holmstrom E, Moritz U: Effects of lumbar belts on trunk muscle strength and endurance: A follow-up study of construction workers. J Spinal Disord 1992; 5: 260-6. CrossRefMEDLINE
Eisinger DB, Kumar R, Woodrow R: Effect of lumbar orthotics on trunk muscle strength. Am J Phys Med Rehabil 1996; 75: 194-7. CrossRefMEDLINE
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: 245-50. CrossRefMEDLINE
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: 58-63. CrossRefMEDLINE
Powers J, Daniels D, McGuire C, Hilbish C: The incidence of skin breakdown associated with use of cervical collars. J Trauma Nurs 2006; 13: 198-200. CrossRefMEDLINE
Plaisier B, Gabram SG, Schwartz RJ, Jacobs LM: Prospective evaluation of craniofacial pressure in four different cervical orthoses. J Trauma 1994; 37: 714-20. CrossRefMEDLINE
Stambolis V, Brady S, Klos D, Wesling M, Fatianov T, Hildner C: The effects of cervical bracing upon swallowing in young, normal, healthy volunteers. Dysphagia 2003; 18: 39-45. CrossRefMEDLINE
Clinic and Polyclinic for Orthopedics and Trauma Surgery, University Clinic Cologne:
Dr. med. Zarghooni, Dr. med. Beyer, Dr. med. Siewe, Prof. Dr. med. Eysel
Center for Clinical Studies, University Hospital Cologne: Dr. med. Zarghooni, Dr. med. Beyer, Dr. med. Siewe