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Pediatric Physical Therapy:
doi: 10.1097/PEP.0b013e3181dc0312
Department: Critically Appraised Topic

Effect of Thoracic Lumbar Sacral Orthoses on Function for Adolescents With Incomplete Spinal Cord Injuries

Hanson, Heather L. PT, DPT

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The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

Correspondence: Heather Hanson, PT, DPT, 2nd floor CSH, Physical Therapy Department, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19143 (hansonh@email.chop.edu).

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CASE DESCRIPTION

A 13-year-old girl presents to an inpatient rehabilitation center after a 2-week acute care stay with an ASIA (American Spinal Injury Association) level C injury, T4 on the right and T5 on the left (motor and sensory). Her medical management included a posterolateral spinal fusion (T2-T8) with corpectomy (T5), and she had full spinal precautions. The rehabilitation team considered whether a thoracic lumbar sacral orthosis (TLSO) may be indicated, given her full spinal precautions, level of injury, and age. The physical therapist was concerned about the balance between functional progress and spinal protection if the team decided to use a TLSO.

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CLINICAL QUESTION

What effect does a TLSO have on function for adolescents with incomplete thoracic spinal cord injuries (SCIs)?

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Literature Search

A literature search was completed using Ovid MEDLINE (1950–2009) and the following search terms: “TLSO” AND “Spinal Cord Injury” and “Pediatrics” AND “Orthotic Devices.” Only 3 of the articles in these searches included pediatric populations or examined functional outcomes. One of those 3 was excluded because it focused on the development of outcome measures and was not clinically relevant to the case and question. The remaining 2 articles were analyzed. A third article was also selected despite the fact that it included a population consisting of age 18 years and older, because it examined respiratory outcomes related to the effects of a TLSO and was clinically meaningful to this patient scenario.

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Citation 1: Impact of Prophylactic Thoracolumbosacral Orthosis Bracing on Functional Activities and Activities of Daily Living in the Pediatric SCI Population1

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Summary of Key Evidence

1. Study design: Cross-sectional case-control design. OTLSO, Ono TLSO and Ono TLSO, OTLSO

2. Sample (n = 14): 6- to 16-year-old children (mean = 10.8 years; 7 boys) with C7-L2 SCI and TLSO use; mean wear time = 33 ± 36 months (range = 2–120 months).

3. Procedure: Participants completed timed motor tests and functional activities scale (FAS) with and without TLSO and indicated preference for completing each activity with or without TLSO.

4. Outcome measures (IV = Use of TLSO; DVs = outcome variables below):

* Timed motor tests (time to complete 6 functional activities). No psychometric information provided.

* FAS (13 activities; scored 1–7 based on independence); activities from expert opinion, no other psychometrics provided.

5. Results: All activities were slower with TLSO except propelling wheelchair on a ramp. Mean times increased with TLSO (by 6%–42%). Scores for FAS were lower for 6 activities but only significant for upper extremity (UE) dressing. Subjects preferred not to wear TLSO for 4 activities and had no preference for 3 activities.

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Appraisal and Application

Internal Validity Threats: (1) No differentiation of lesion sites and types of SCI may mask differences between subjects; (2) no randomization or blinding limits validity; (3) wide range of time subjects who had worn TLSO before study may confound scores; (4) no report of reliability or validity of outcome measures; (5) grouped all children aged 6 to 16 years in the sample, without assessing skeletal maturity, which may cause differences between subjects, and in outcomes; (6) no differentiation between rigid versus flexible TLSO may confound results; (7) no specific description of TLSO used; and (8) no evaluation of differences between subjects before testing.

Internal Validity Strengths: (1) Specific inclusion criteria to create similar groups; and (2) alternated starting conditions to eliminate bias.

External Validity Threats: Limits generalizability: (1) No specification of type of SCI (ASIA level); (2) grouping all spinal levels (C7-L2); (3) a single-site study with convenience sample; and (4) no specific description of TLSO used.

External Validity Strengths: (1) Wide age range of subjects improves generalizability; (2) stated inclusion criteria allow specification of population; (3) equal numbers of males and females improves generalizability; and (4) outcome measures are easily reproducible in a clinical setting.

Statistical Validity Threats: (1) No report of reliability or validity of outcome measures limits statistical rigor; and (2) no statistical evaluation of baseline differences.

Statistical Validity Strengths: (1) Used appropriate nonparametric statistical analyses; (2) used correction for nonnormal data; and (3) complete data reporting.

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Citation 2: Effect of Thoracolumbosacral Orthosis on Reachable Workspaces Volumes in Children with SCI2

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Summary of Key Evidence

1. Study design: Case-control design.R OTLSO, Ono TLSO

2. Sample (n = 20): 5 to 18-year-old children (10 boys), with C7 or below SCI (18 ASIA A, 2 ASIA C) and TLSO as a part of clinical care.

3. Procedure: Participants were seated in a standard chair with reflective markers placed for UE motion analysis, and then were asked to reach as far as they could for targets placed at heights in 20° increments to the left, right, and front. Participants were tested in random order with and without TLSO.

4. Outcome measures: (IV = use of TLSO; DVs = outcome variables below).

* Reaching volume (to left and right; with and without TLSO).

* Range of reach in anterior-posterior (AP), medial-lateral (ML), and vertical directions.

5. Results: Mean reaching volume was higher without TLSO (increased by 4.9%–77.3%). Six subjects had larger volume with TLSO. Without TLSO, the average range of reach was slightly higher than that with the TLSO in the AP, ML, and vertical directions but was only statistically greater in the AP and ML directions. No significant difference when comparing dominant and nondominant reach in all directions with or without TLSO.

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Appraisal and Application

Internal Validity Threats: (1) No report of length of time since SCI or length of time TLSO was worn before study may create unequal groups and confound results; (2) no differentiation between rigid or flexible TLSO may confound outcome; (3) no specific description of TLSO used; (4) grouped all children aged 5 to 18 years, without assessing skeletal maturity, which may mask differences between subjects, and in outcomes; (5) no report of reliability or validity of UE motion analysis used; (6) variable levels of SCI (spinal level and ASIA level) may confound results; (7) no evaluation of baseline differences between subjects may influence outcome; and (8) no blinding may create bias.

Internal Validity Strengths: Randomized conditions to eliminate bias.

External Validity Threats: (1) A single-site study with convenience sample limits generalizability; (2) primarily ASIA A level injury limits generalizability to incomplete injuries; and (3) no specific description of TLSO used.

External Validity Strengths: (1) Wide age range of subjects improves generalizability; and (2) equal numbers of males and females improves generalizability.

Statistical Validity Threats: (1) No report of reliability or validity of outcome measures limits statistical rigor; and (2) no statistical evaluation of baseline differences.

Statistical Validity Strengths: (1) Used appropriate statistical analyses; (2) P value set a priori improves validity; and (3) complete data reporting strengthens statistical validity.

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Citation 3: Respiratory Effects of Combined Truncal and Abdominal Support in Patients with SCI3

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Summary of Key Evidence

1. Study design: Cross-sectional case-control design.R, Day 1: Owith girdle, Ono girdleDay 2: Owith girdle, Ono girdleDay 3: Owith girdle, Ono girdle

2. Sample (n = 10): 18 to 56-year-old patients (6 males) with stable C5-T6 SCI (ASIA A; time since injury = 3–27 months); all wheelchair bound and wearing an abdominal girdle.

3. Procedure: Subjects underwent pulmonary function tests on 2 consecutive days and inspiratory muscle function testing on a separate day; both conditions with and without girdle.

4. Outcome measures: (IV = Use of girdle; DVs = outcome variables below)

* Pulmonary function tests (via spirometry to measure flow-volume curves and lung volumes).

* Pattern of breathing (via respiratory inductive plethysmography).

* Inspiratory muscle function (via catheter-mounted pressure transducer and via magnetic phrenic nerve stimulation).

* Modified Borg scale (sensation of respiratory effort).

5. Results: With the girdle, increase in inspiratory capacity, forced vital capacity, peak expiratory flow, and forced expiratory volume in 1 second; functional residual capacity and Borg rating decreased; thoracic component of breathing pattern increased; and diaphragmatic load and trans-diaphragm pressure increased. There was no change in maximum expiratory pressure.

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Appraisal and Application

Internal Validity Threats: (1) No report of time girdle was worn before study may confound scores; (2) wide range of time since injury may create differences in baseline respiratory function; and (3) no differentiation between rigid or flexible TLSO may confound outcome.

Internal Validity Strengths: (1) Specific inclusion criteria create similar groups; (2) blinding of data analyzers eliminates bias; (3) randomized testing condition of with or without girdle eliminates bias; and (4) report of procedure and reliability/validity of testing measure improves validity.

External Validity Threats: (1) Inclusion of only ASIA A level injury limits generalizability to incomplete injuries; (2) a single-site study with convenience sample limits generalizability; and (3) no inclusion of adolescent subject limits generalizability to this age.

External Validity Strengths: (1) Wide age range of subjects improves generalizability; (2) stated inclusion criteria allow specification of populations to which results can be generalized; and (3) outcome measures used easily reproducible in a clinical setting.

Statistical Validity Threats: No statistical evaluation of baseline differences.

Statistical Validity Strengths: (1) P value set a priori; (2) complete data reporting; and (3) used appropriate statistical analyses for data.

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REFERENCES

1. Chaftez RS, Mulcahey MJ, Betz RR, et al. Impact of prophylactic thoracolumbosacral orthosis bracing on functional activities and activities of daily living in the pediatric spinal cord injury population. J Spinal Cord Med. 2007;30(suppl 1):S178–S183.

2. Sison-Williamson M, Bagley A, Hongo A, et al. Effect of thoracolumbosacral orthoses on reachable workspaces volumes in children with spinal cord injury. J Spinal Cord Med. 2007;30(suppl 1):S184–S191.

3. Hart N, Laffont I, Perez de La Sota, et al. Respiratory effects of combined truncal and abdominal support in patients with spinal cord injury. Arch Phys Med Rehabil. 2005;86:1447–1451.

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Clinical Bottom Line

In the studies reviewed to address the clinical question specific to a 13-year-old girl with an incomplete spinal cord injury (SCI), use of a thoracic lumbar sacral orthosis (TLSO) limits speed of functional activities, ability to perform some, but not all functional activities, reaching volume, and range of reach in a seated position. In subjects with complete injury, use of an abdominal/truncal girdle improves lung volumes, diaphragmatic strength, and decreases abdominal compliance. Subject preference is variable for the use of TLSO and differs based on the type of activity.

The studies reviewed did not separate groups by several factors important to the clinical question. They did not differentiate between children and adolescents; cervical, thoracic, or lumbar SCI; incomplete versus complete SCI; or type of TLSO used. Differences between children and adolescents, including skeletal maturity, may influence the clinical decision to prescribe a TLSO, given the risk of progressive scoliosis after SCI in a skeletally immature patient. Differences between different spinal levels of SCI and between incomplete and complete SCI may also lead to differences between subjects in strength, functional ability, and need for a TLSO. Differences between rigid and flexible TLSO may also affect functional ability and performance on functional outcome measures. Further studies should be done to differentiate between these groups.

The literature available did not provide enough specific information to determine a definitive answer to the clinical question; however, a decision was still needed to be made for the clinical case. Given that the studies reviewed showed that a TLSO has a variable impact on function, has the potential to improve respiratory function, and has variable patient preference; for this particular patient, we initially used a TLSO for trunk stability and respiratory support. Still, individual decisions for the use of a TLSO should depend on treatment goals, level of injury, and individual patient needs until further literature is available to specify aforementioned groups.

© 2010 Lippincott Williams & Wilkins, Inc.

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