Bracing for Low Back Pain

Key Points—

• Proper orthotics prescription requires knowledge of the biomechanics of the Thoraco-lumbar spine and general principles of bracing, including their indications and limitations.
• Spinal orthoses utilize the principle of three-point pressure control. The corrective component is typically and ideally located midway between the opposing forces.
• Spinal orthoses may be used as an adjunctive treatment for various conditions that can cause low back pain, including vertebral fractures, facet joint arthritis, degenerative intervertebral discs, scoliosis, neuromuscular disease, spinal cord injury, and myofascial and ligamentous injuries.
• Spinal orthotics prescriptions for uncomplicated low back pain should be discouraged.
• Prescription of a spinal orthotics should be made only after careful clinical assessment, including a detailed history and extensive physical examination. Ancillary testing helps the clinician to choose an orthotics that best meets the biomechanical demands of the lumbar spine disorder. Diagnostic imaging may not be needed in all cases.
• Prescription of spinal orthoses should be accompanied by specific activity restrictions to help ensure protection from injury progression.
• Lumbar spinal orthoses should be considered for short-term use as a part of a comprehensive rehabilitation program; exceptions include spinal metastasis and severe cases of osteoporosis.
• When indicated, the patient may perform therapeutic exercises while wearing the orthoses. In certain cases, such as acute spondylolysis or acute compression fracture, the patient should not exercise even while wearing an orthoses until adequate healing is ensured.
• No lumbar orthoses provides absolute spinal immobilization. Rather, they partially limit spinal motion.
• Variations in body habitus (i.e. obesity) may render an appropriately selected orthoses ineffective.
• A poor response to bracing warrants a re-evaluation of the diagnosis, treatment plan and orthotics prescription.
• To prevent psychological dependence, patients should be weaned from their orthoses rapidly, when clinically appropriate.
• Like any prescriptive treatment, spinal orthotics involve the potential for abuse and noncompliance. The appropriateness of any prescribed orthoses may vary as the patient’s condition changes over time.
• Long term use of lumbar orthotics should be discouraged in most cases secondary to potential adverse effects, including possible loss of strength of core body musculature, psychological dependence, and decreased spinal mobility.
• Scientific literature has not conclusively demonstrated that lumbar supports significantly prevent low back injuries in the industrial population.

I. Goals of Spinal Orthotic Prescription

1. Truncal support and control spine position by use of external forces
2. Restriction of gross spinal and segmental motion
3. Partial unloading of spinal segments (anterior vs. posterior)
4. Stabilization of spine when soft tissues cannot adequately perform this function (ie. Fractures)
5. Proprioceptive feedback and postural control
6. Reinforcement of proper body ergonomics
7. Warmth to underlying soft tissues
8. Compression or cushioning of paravertebral soft tissues by design
9. Apply corrective forces to abnormal curvatures

II. Indications for Use of Spinal Orthotics

1. Spondylolisthesis
2. Spondylolysis with or without spinal instability
3. Degenerative intervertebral disc, including herniation
4. Rheumatic diseases
5. Severe osteoporosis
6. Vertebral compression fractures
7. Chronic muscle weakness
8. Pain that is not responsive to therapeutic exercise
9. Scoliosis
10. Spinal cord deformity
11. Neuromuscular disease

III. Principles of Orthotic Mechanism of Action

1. Range of motion (ROM) is restricted by a 3-point pressure system that provides spinal support by means of opposing forces.
2. Increases proprioception secondary to increased cutaneous input.
1. Results in enhanced awareness of pelvis and spine and improved posture.
2. Prevents motion into painful positions.
3. Reflexive muscle relaxation through body heat containment by the orthoses.
4. Soft-tissue swelling and edema control by compression of paravertebral soft tissues.
5. Increased trunk support aids weak abdominal muscles and increases intra-abdominal pressure (IAP), thus mechanically unloading the intervertebral discs. (Increased IAP reduces the tension on the posterior spinal muscles.)
6. Improved posture; more balanced load distribution through lumbar spine and pelvis.
7. Possible decrease in muscle strength and endurance with long term use (controversial).

Michael Wolff, M.D., Michael Weinik, D.O., Ian Maitin, M.D.
Reprinted with permission from The Low Back Handbook, ©2003