An Orthotist’s Dilemma: We Have Your Back—But Does it Need Bracing?
January 2015 Issue
At some point, as much as 80 percent of the population will suffer from back pain.1 The Agency for Healthcare Research and Quality claims that in 2007 alone, about 27 million U.S. adults age 18 or older (11 percent of the adult population) reported having back pain, 70 percent of whom sought medical treatment.2
Back pain, especially low back pain (LBP) and chronic LBP, is a common problem. At some point, as much as 80 percent of the population will suffer from back pain.1 The Agency for Healthcare Research and Quality claims that in 2007 alone, about 27 million U.S. adults age 18 or older (11 percent of the adult population) reported having back pain, 70 percent of whom sought medical treatment.2
The Journal of the American Medical Association (JAMA) reports that spine care costs reached $85.9 billion in 2005,3 and JAMA Internal Medicine further reports that LBP "is the second most common cause of disability in U.S. adults and a common reason for lost work days. An estimated 149 million days of work per year are lost because of LBP… [resulting in total costs] estimated to be between $100 and $200 billion annually, two-thirds of which are due to decreased wages and productivity."1
Back pain is second only to upper respiratory conditions as the stated cause of work loss, notes Gerald W. Browning, PhD, PT, School of Health Professions, University of Missouri- Columbia. "The costs for treatment and compensation for LBP in industry may be greater than the total amount spent on all other industrial injuries combined. However, most of the costs, perhaps 80 percent, are incurred by about 20 percent of the LBP patients who then become disabled."4
What's the best way to address this painful and costly issue- and what role should orthotic practitioners be expected to play? We asked physicians and orthotists to share their expertise and insights regarding short-term bracing solutions for common spinal injuries.
BRACING OR SURGERY, OR BOTH?
From athletic injuries to bulging or herniated disks, there are a number of conditions that affect the spine for which surgery may not be the only option. According to a fact sheet published by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, most people with chronic back pain do not need surgery; it is usually used for chronic back pain if other treatments do not work.5 The publication notes that recent research is focusing on cost and effectiveness comparisons of surgical versus nonsurgical treatments for various types of back pain.
Patrick W. Hitchon, MD, Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, is among those pursuing this research; in a 2014 study, he and his colleagues report that 51 out of 60 patients were successfully treated nonoperatively for T11-L4 thoracolumbar burst fractures, using only bed rest and bracing until the pain abated sufficiently to allow mobilization.6
The majority of the back pain sufferers Hitchon sees in clinic are experiencing the simple wear and tear that comes with age, he says. "Many of them have had expensive operations with screws and rods and hardware for the treatment of back pain. But a lot of patients, even with fractures, can be treated successfully without surgery, given time, rest, and anti-inflammatory medication or relaxants; and less than 10 percent may end up requiring surgery. If there is muscular pain, aggravated by motion, a brace can help.
"Some studies have shown, however, that patients will recover equally well long term, with or without bracing," Hitchon observes. "So the role of bracing in spine management is coming under scrutiny, and the reason is, perhaps, because of the cost of these devices, some of which cost $2,000 or more."
Hitchon notes that 40 years ago, fracture management literature supported the use of bracing, especially in Europe, where, as a student, he recalls putting body casts on patients with spinal fractures. He says the theory was that casted fractures would heal faster and that it would prevent deformity, but that over the past three to five years there has been some skepticism regarding the necessity of bracing since "patients do equally well whether you brace them or not."
Adam Finnieston, CPO/L, Arthur Finnieston Prosthetics + Orthotics, Miami, notes that Maramed Orthopedic Systems, Hialeah, Florida, a manufacturer of off-the-shelf (OTS) fracture bracing developed in the 1970s by his father, Arthur Finnieston, has experienced a systematic slowdown because of the prevalence of internal fixation (i.e., surgery). "With the current focus on containing healthcare costs, however," he says, "people are noticing that it's a lot less expensive to treat patients with a brace than to use surgical intervention." He also points out that while back bracing is still being used, in his experience, adults with LBP, including stress fractures and herniated disks, are being fitted less by O&P professionals than by physicians and other providers. "The vast majority of low back pain treatment across the country, and specifically in the larger markets, has been taken away from the traditional O&P community by doctors, rehab facilities, or manufacturers' reps. The prevalence of off-the-shelf systems has made it easy for fitters to achieve satisfactory results with those items, just as it happened in the past with knee bracing."
Most of the low back care Finnieston provides is focused on pediatric postoperative orthoses, which are fit as temporary bracing to help the surgical site heal, he says.
Traci L. Romano, CPO, Harry J. Lawall & Sons, Philadelphia, says she already may be seeing a trend toward less surgery among the patients with LBP whom she fits. "Some back braces are fit pre-surgery, because the patient will need to wear it for extra stability post-surgery," she explains. "But the majority of [LBP] patients are the result of sports injuries or excess weight, and we use standard off-the-shelf designs that support their lumbar spine."
Without research studies and physician's records there's no way to know how successful bracing might be as a substitute for surgery, says Romano. "It's very difficult to know. If patients come in with standard low back pain, they may not need routine follow-ups with us, especially if they're seeing a physical therapist. If the brace is working for them, they're done with us; and conversely, if they decide to give up on the brace for whatever reason, they typically don't come back to tell their orthotist."
If the brace is fit preoperatively, she cautions that she is unsure how long that relief is going to last over an extended period. "It will depend on what other comorbidities are causing the issues with the back pain." Since the newer braces are designed for greater comfort, with lower profiles and less bulk so they can be worn inconspicuously under clothing, improved compliance may also result in a higher degree of effectiveness and more successful nonsurgical outcomes, Romano postulates.
Communication with the patient's physician is key to successful outcomes in most cases, she believes. "If they are surgeons or doctors looking more toward bracing as a conservative option, then we can educate them as well, letting them know what's out there and how we can work together to choose the right brace for the patient from the hundreds of options available."
Jake Jacobi, CO, LPO, the director of orthotics with Snell Prosthetic and Orthotic Laboratory, Little Rock, Arkansas, points out that there are pros and cons to bracing for LBP. "The Mayo Clinic has predicted that four out of five people are going to have some type of back pain in their lives," he says. "We're finding from experience that if we can immobilize these patients and they take some type of anti-inflammatory drugs, sometimes their back will calm down on its own, especially when combined with physical therapy. But there's also the danger of a patient becoming too dependent on the brace, which can allow their own muscles to atrophy-and we don't want them to lose muscle strength. If patients are undergoing physical therapy, we don't want their dependence on the brace to interfere with strengthening the back itself," he warns.
"I caution patients to wear the brace according to their physicians' instructions. Some doctors want them to wear the braces at night, and some don't. Each might have a different protocol; an orthopedist may have a different strategy than a neurosurgeon."
Although he recalls that patients with herniated disks were once hospitalized for a week in pelvic traction as a viable option to surgery, this is no longer done-probably because today's hospital costs are significantly higher than previously. "The cost of in-and-out surgery is much more attractive from an economic standpoint than a weeklong hospital stay," he says. The more conservative option of bracing to see if the problem can be resolved without surgery should be even more economically attractive, he adds.
And while compliance is often an issue with orthotics patients, it may be less so with patients who suffer from LBP, Jacobi finds. "Generally, if they're in pain, patients will wear their braces; pain is a great motivator. How long they stay in the brace depends on the patient and their situation. Many low back pain patients are not long-term brace wearers; four to six weeks is the average, from my experience."
COMPARING LONG-TERM OUTCOMES
Hitchon points to studies that demonstrate that at one year post-treatment, patients who have undergone surgery do just as well as patients who haven't-and vice versa. At the end of that year, the patients who did not have surgery catch up in terms of recovery from their back injury to those who did. So, while removing a herniated disk may be helpful in alleviating the patient's pain more promptly, at the end of the year, there's little or no difference in his or her condition.
"Back pain from disk herniation can prove disabling in the short term," he notes. "People are expected to resume normal activities, including their jobs, within a reasonable period of time. A return to work earlier than later is, most of the time, of the essence. Conservative treatment with physical therapy, analgesics, and relaxants may suffice. Epidural steroids are also helpful. Once everything fails and the patient is suffering from disabling pain, surgery may be the only remaining option. Not every herniated disk needs an operation, and I think we are moving toward that more realistic approach. Surgery is expensive and not without risk."
Hitchon cites cases of patients who developed infections as a consequence of their surgeries and struggled with the pain and antibiotic battle for as long as a year, while about 10 percent of patients develop re-herniation and must repeat the surgery-sometimes more than once.
In comparison studies of patients who have and have not had surgery, those who have had surgery are more likely to complain of pain in the future than those who have not had surgery, Hitchon notes. "Their bodies have been invaded; their anatomy has been distorted. They're more likely to have scarring and irritation of the nerves as a result of surgical intervention," he points out.
"The other problem with surgery is that it creates a stigma. If you apply for a job and you mention in your medical history that you have had back surgery, some employers may be more reluctant to hire you. It is not unusual for those who have had back surgery to call in once or twice a year with exacerbation of back pain," he says.
From the surgeon's perspective, "The bottom line is patient selection and making sure that the situation is unlikely to get spontaneously better before undertaking surgery," Hitchon says.
The jury is still out on the relative value of bracing as an alternative to surgery in patients who suffer from LBP without neurological deficits, but the current focus on more conservative options to back surgery would seem to be a promising sign for orthotists, Jacobi believes.
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
- Freburger, J. K, G. M. Holmes, R. P Agans, A. M. Jackman, J. D. Darter, A. S. Wallace, L. D. Castel, W. D. Kalsbeek, and T. S. Carey. 2009. The Rising Prevalence of Chronic Low Back Pain. JAMA Internal Medicine 169 (3):251-8.
- Soni, A. 2007. Back Problems: Use and Expenditures for the U.S. Adult Populations. Statistical Brief #289. Medical Expenditure Panel Survey. Agency for Healthcare Research and Quality. July 2010. www.meps.ahrq.gov/mepsweb/data_files/publications/st289/stat289.pdf.
- Martin, B. I. R. A. Deyo, S. K. Mirza, J. A. Turner, B. A. Comstock, W. Hollingworth, and S. D. Sullivan. 2008. Expenditures and Health Status Among Adults With Back and Neck Problems. JAMA 299 (6): 656-64.
- Browning, G. W. 2012. Mechanical Low Back Pain: Prevalence and Costs. Virtual Health Care Team. shp.missouri.edu/vhct/case1699/preval_costs.htm.
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. Updated September 2009. What is Back Pain? Fast Facts: An Easy-to-Read Series of Publications for the Public. www.niams.nih.gov/health_info/back_pain/back_pain_ff.asp.
- Hitchon, P. W., W. He, S. Viljoen, N. S. Dahdaleh, R. Kumar, J. Noeller, and J. Torner. 2014. Predictors of Outcome in the Non-operative Management of Thoracolumbar and Lumbar Burst Fractures. British Journal of Neurosurgery 28 (5): 653-7. informahealthcare.com/doi/abs/10.3109/02688697.2013.872226.