If The Brace Fits -- Wear It!

'You only come to see me to have your own views confirmed don't you!' my 'orthopod' said with a smile as he examined my new brace. 'Fine. If you are happy with that, then continue to wear it and come and see me in a month - earlier if there's any change for the worse.

I considered myself fortunate in my choice of orthopaedic surgeons. (Actually, he had been recommended by a medico friend whom I had known since undergraduate days.) He had looked after me since my discharge from hospital and during my subsequent convalescence, was a great believer in conservative treatment and advocated surgery only as a last resort. This was an attitude with which I totally concurred!

His pragmatic approach was probably not shared by all of his colleagues, but he had been open about the professional dichotomy that can exist between prescribers and providers of orthopaedic appliances. 'They know more about the technical aspects than we do, but still depend on us to make the decisions regarding what to prescribe' he said. I pointed out that the patient might sometimes like to be consulted too and he laughed and agreed. 'Some show interest in their management as you do others just want to be told. It's actually easier if patients show an intelligent interest. They are likely to be happier with their treatment and their compliance will be higher if they have had input into it.'

This conversation was taking place because I had received a bit of a setback. Weaned from the spinal brace (CTLSO) that had given me mobility whilst the fractures of my cervical and thoracic spine had healed, I found that I still had a neck problem. My 'orthopod' pointed to the radiograph. 'You see that', he said. 'It shows the damage to the ligaments connecting your vertebrae. Bones heal completely, but joints may not and ligaments are replaced by scar tissue which is not as elastic. This will take longer to settle down, and we'll have to watch it. I don't think a fusion will be necessary, but it's a possibility in the future which we may have to face. In the meantime, you'll need to continue to wear a neck brace and we'll keep a close eye on it' I didn't have much of a problem with that. Braces beat the hell out of operations and you would find yourself back in a brace post-operatively anyway. Besides, after several months I was getting used to them!

The orthotist looked at the prescription which was a general one for a cervical brace which would'... prevent flexion, extension and rotation, particularly at the C4-5 level. 'Well, that collar isn't going to do that.' I agreed as I removed the plastic collar that I had worn in bed in the hospital and since leaving the restrictive but trusty confines of my full spinal brace. He went out and returned with some boxes.

'We'll try this first, it's a fairly inexpensive alternative, but I don't think it will meet the rotation requirement.' he said as he produced what I recognized from the reading I had done recently (in the medical library of my old University) as a 'four- poster' brace. The straps between the front and back plates were buckled over my shoulders and under my arms and the occipital and chin pads similarly joined. The four struts were extended by a screw-thread mechanism as I was asked 'How does that feel?' 'Fine, except that I can turn my head from side to side more than I could in my full brace' I replied. He nodded. 'I think we had better try something a bit firmer' he said as we took the brace off.

The next piece of equipment was rather more fearsome and reminded me to some extent of my full (CTLSO) brace. It had two posts holding the chin and occipital pads (which were again joined by straps and buckles) and these went down to pads in the middle of my back and below my ribs. Over the shoulders was a rigid frame attached to the posterior post and this was attached by adjustable straps to a breast plate screwed to the front post. The lower pads were similarly joined by webbing straps around my waist. 'You can adjust the traction on your neck with these shoulder straps' I was told 'and there is a safety override to prevent too much force being applied.' To prove the point I pulled them tight and, sure enough, the breast plate parted with the front post where it had been held by a spring-loaded clip.

This brace, made by a firm in Florida I later discovered, cured the rotation problem and prevented practically any movement of my neck. However it was not all that much less extensive than the CTLSO that had cradled me for the past few months! 'What else do you have in the armory? Something in between perhaps?' I enquired as the second brace came off. 'This is about the only other possibility for the degree of immobilization you need' came the reply as he took the third brace out of its box. I recognized this as a 'sterno-occipital-mandibular immobilizer' or SOMI.

The chest plate (the 'sternal' part) with its rigid shoulder bars, was strapped to my chest and the chin ('mandibular') piece attached by its ingenious mechanism. The orthotist held the occipital pad in place by hand as I was again asked for my initial impressions. 'Best so far' I said. The orthotist set the ferrules in place on the rod that holds the occipital pad and showed me how it attached to the chest plate by a similar mechanism. (Both the chin piece and the rod holding the occipital pad are held by plastic blocks, their position determined by spigots or ferrules respectively, and locked in place by plates that slide over to close them.) Once adjusted, the uprights attach in the same position each time. Similarly, the straps holding the (chin and occipital) pads together only need to be adjusted once and thereafter clip on with snap fasteners.

Getting into and out of this rig was going to be much quicker than with my CTLSO, with its multitude of straps and buckles. I was satisfied that the SOMI was the best of the three alternatives for me so, with final adjustments made, I left with my bead once again held high and supported by metal struts (three this time) appearing from an arcane structure strapped to my body beneath my clothes. This time, however, there was rather less of it!

I make no apology for my frequent references to comfort in these accounts. It is second only to function in my view and if you don't know why, try wearing a brace for a few months! On comfort, the SOMI scores very highly. Soft foam covers all surfaces which are in contact with you, and being of the closed-cell variety, it doesn't absorb moisture. It is generally advisable to wear a T-shirt or skivvy under a brace for comfort and hygiene also. The brace is easily put on and removed. After putting the chest plate on with its the chin piece already attached, and tightening the webbing straps which cross around the back of your chest and attach to the bottom of the plate, the rod supporting the occipital pads is attached also and the (thin white leather) straps joining them snapped into place. Compared with getting into my CTLSO, I found it a very quick operation.

There is also a headband that comes with a SOMI. It attaches to a plastic extension clipped to the occipital pad instead of the straps. It's purpose is alleged to be to hold the head whilst the chin piece is removed to eat, shave etc.. My view is that, given the flexibility of the SOMI's posterior rod, it is more of a reminder to stay still than a positive support.

The ligamentous damage to my neck took several more months to settle down to the extent that I could wear a less restrictive collar again. Back in my plastic collar in hot summer weather, I again investigated alternatives. What I obtained was a wireframe device, and a similar plastic one, of which more later. These, and later a soft collar, I wore until I could discard them also.

My career had taken me to another state two or three years later when my syndrome flared up again, as it has from time to time since, and it was here that I found my next approach to controlling it. It was at a party that I met a woman who was also in a neck brace. I was wearing my SOMI and her neck was immobilized in a plastic collar so closely fitting that it must have been made for her. Not surprisingly, we swapped experiences! She was not an accident victim, she told me in answer to my inquiry. Rather, she had a long-term problem with cervical spondylitis inflammation of the intervertebral joints. In her collar, she couldn't move her neck at all, she indicated, and that suited her as it controlled the pain and protected her joints. I could believe the high degree of immobilization. The collar enclosed her chin and lower jaw and, holding back her hair, she showed me how it extended up to behind her head. Similarly, it extended down to her upper back and chest. It was made in two parts held together by four doubled-back velcro straps. I had seen pictures of similar collars before in, I think, a British medical text. These had been of moulded leather, though, and this was my first introduction to a thermo-plastic one.

She said that she was quite comfortable (these things are relative) in her 'doll's collar' as she called it and, as I had noticed, her brace was relatively inconspicuous compared with mine. There were no metal struts of course, and the only part really visible was the plastic cradling her chin. Her hair covered the back of it and a high-neck sweater and scarf most of the remainder. On inquiry, she gave me the address of the orthotist who had made it for her.

Yes, he could make one for me also, I was told when I enquired, and I made an appointment for the taking of the plaster cast of my neck that its fabrication would require. The cast enclosed my neck, upper thorax, chin and the back of my head and was removed when almost set to form the negative of a positive plaster mould around which the collar would be formed to my exact shape. I was to return for a fitting in about a week.

As I have indicated, a doll's collar is a 'bivalved' design with posterior and anterior halves. They mesh together with a stepped junction so that, when you put it on, the two halves are always in the same relative position. Velcro straps hold them together. At my fitting, the collar was placed around my neck and the straps pulled firm. It was a very new experience!

Those of you who have worn a neck brace, even a fairly restrictive one like a SOMI, will know that movement is not totally prevented. Although held fairly firmly in the mid-cervical region, you can get some rotation, lateral bending etc. in the upper cervical segments. In the literature there are comparative studies of cervical cervical orthoses which give quantitative measurements of possible movement in various planes and at different levels. The SOMI for instance, because of its relatively flexible posterior support, can allow quite a lot of extension if little flexion. You don't generally let it happen, as your head is held firmly by the chin piece, but it can occur.

(If you are interested, there is an example by Hart et al in the journal Physical Therapy of July 1978, and this refers to a more technical article by Johnson et al in another journal the previous year. A more recent reference is the 1994 article by Lunsford et al in the Journal of Prosthetics and Orthotics. Apparently, even a halo vest does not entirely eliminate movement but must come close. Happily I have never had to find out!)

Well, the doll's collar was different! It was the closest I have come to having my head and neck held completely rigid. Because the chin is held so snugly and the posterior shell extends up behind your head, flexion, extension and rotation can hardly occur at all. Due to the total contact of your neck, chin and upper thorax with the collar, practically nothing moves, especially in the mid-cervical region. This collar became my preferred orthosis whilst my problem was acute and it still is. It can be more readily worn under clothing, and is, as I have mentioned, relatively inconspicuous, especially under a skivvy or turtle-neck sweater.

I generally dispense with a tie when wearing a neck brace (it's impossible to wear one with most of them anyway) but it is actually possible with a doll's collar. I have a couple of business shirts with (about 5 cm) oversize collars and, when the occasion requires, I can wear the shirt and a tie over the brace. I come back yet again to comfort and it is here that the doll's collar wins again. Although it is rigid and only padded under the chin with some thin foam, it contacts the skin over a large area and, by simple physics, skin pressures are low. A doll's collar's only real disadvantage I have mentioned before - problems in hot weather.

When I met the same lady the next time we, by now orthotic 'Bobsie Twins', again exchanged experiences. As I remember, the things that we discussed were the ease of wearing our collars with ordinary clothes and their cosmetic appearance. (She had the further advantage over me of long hair to cover the back of hers and had grown it for that purpose.) After function and comfort, cosmetic appearance is fairly important to wearers of neck braces - especially to those of us who, like her and me, were or are committed to long-term use.

The open collars that I wear as my syndrome settles down again are worth a brief mention. One is a padded wire frame that sits under the chin and curves down on each side of the neck to rest on the upper part of the sternum. It is attached by straps around the nape of the neck. I have a similar one where the wire is replaced by padded plastic. Compared with the 'heavy metal' (or 'heavy plastic'!) I have described above, these give little support - restricting as they do, not much more than flexion. They are more or less equivalent to a plastic collar but are cooler in hot weather, less conspicuous and, again, easier to wear under most clothing. I don't think that a soft collar needs much explanation and you may have read my account of the modern Minerva brace, which I have more recently acquired, elsewhere.

You will see that taking what is hopefully an intelligent interest in your own condition, should you find yourself in the situation where you must wear a neck brace, can optimize both function and your comfort and appearance. Having cooperative professional advice helps, but I have found that that is readily forthcoming if you bother to do your homework, respect professionals' knowledge and ask the right questions. Another point emerges also - that networking with others who wear braces, if you have the opportunity to do so, can be a very mutually beneficial activity. After all, the people who know the most about what it is like to wear cervical braces, and how effective they are, are the people who wear them. What may also come through is that you don't really know what a particular brace is like until you try it!

Oh yes, although I still wear neck braces from time to time, I've avoided a spinal fusion operation. Inconvenient they may be, but braces sure are preferable to surgery!

The above story is more great work from the author of Spinal Fracture Again this story was based on true facts --- Our thanks to the anonymous author for a another great job -- we look forward to more stories in the future!

Sincerely,
Binkly

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