Injury 54 (2023) 110986

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Thoraco-lumbar-sacral orthoses in older people – A narrative

literature review
Surabhi Varma 1, Kevin Tsang, George Peck *
Major Trauma Center, St. Mary’s hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, U.K

A R T I C L E I N F O A B S T R A C T

Keywords: Fractures in the thoracolumbar region have a bimodal distribution, with an increasing number of older people
Elderly trauma presenting with acute vertebral fractures after atraumatic or low energy mechanisms of injury.
Thoracolumbar orthoses In the absence of neurological compromise and significant vertebral instability, thoracolumbar fractures are
Vertebral fracture
often managed conservatively and bracing is widely recommended. However, in older cohorts, bracing is often ill
fitting and poorly tolerated with non-compliance leading to prolonged immobilization. Systematic reviews and
meta-analyses have challenged the motive of bracing, but as evidence quality is low, the role of exploratory
analysis has been limited. This descriptive review summarises and examines the current evidence that underpins
the use of spinal orthoses, specific to older patients, in an effort to streamline its judicious use in clinical practice
and identify scope to direct further research.

Introduction tactile and proprioceptive input to facilitate balance. Improved fracture

The ageing spinal column has an inherent biomechanical fragility
characterised by reduced bone quality and bone mineral density,
degenerative changes with spinal canal narrowing, dehydration of discs
causing stress shielding and reduced elasticity and strength of stabilizing
ligaments [1,2]. Subsequently, older people have an increased pro­
pensity to vertebral fractures and spinal cord injury even with low en­
ergy mechanism of injury [1]. Surgical intervention is less frequent in
older cohorts largely due to the nature of injury, the presence of
comorbidities and structural changes of the ageing spine [3]. In patients
where surgical management is not indicated or suitable, conservative
management of thoracolumbar fractures has evolved from traditional
prescription of prolonged bed rest, to promotion of early ambulation-
often supported by the use of stabilizing orthoses.
The hypothesis is that external bracing reduces gross spinal motion
and applies pressure along the sagittal plane to maintain neutral spinal
alignment and prevent neurological and morphological instability.
Reduced anterior load on the vertebral column through intra-abdominal
compression is thought to reduce kyphotic deformity, which is consid­
ered to be the main cause of longer-term pain and disability. It provides
healing, reduced pain and early ambulation are other intuitive benefits
of external thoracolumbar support, but the evidence base remains
controversial, particularly in older adults.
There are three main types of thoracolumbosacral orthoses (TLSOs).
The traditional rigid TLSOs such as Jewett brace or Knight-Taylor brace
provide more rigid stabilization but are poorly tolerated and may lead to
para-spinal muscle atrophy [4,5]. Custom or off-the-shelf semi-rigid
TLSOs are less rigid alternatives when severe spinal restrictions are not
indicated. Spinal dynamic orthoses (SDO) are less restrictive braces with
a primary role in biofeedback activation of spinal muscles [6]. They
compliment physical training but offer little benefit in mechanical
immobilization.
Many perceive that orthoses are particularly poorly tolerated in older
patients, but they continue to be commonly used in clinical practice. In
the absence of robust clinical trials, the role of systematic analyses is
limited. This narrative review summarises current knowledge around
the use of TLSOs in vertebral fractures, specific to older adults. It aims to
understand the advantages they offer, misperceptions in current practice
and disparities between empirical practice and state of evidence.

Funding: Open access fee provided by Cutrale Perioperative Ageing Group

* Corresponding author at: Department of Medicine for the Elderly, Mary Stanford Wing, St Mary’s hospital, Praed Street, London W2 1NY, UK.
E-mail address: g.peck@nhs.net (G. Peck).
1
Permanent address for Surabhi Varma: West Middlesex University Hospital, Chelsea & Westminster NHS Foundation Trust, Twickenham Road, Isleworth, TW7
6AF, U.K

https://doi.org/10.1016/j.injury.2023.110986
Accepted 5 August 2023
Available online 9 August 2023
0020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Varma et al.
Methods
We conducted a literature search using PubMed database (Fig. 1) on
7th May 2023. The search strategy was kept broad to include grey
literature and employed keywords, titles, abstracts and medical subject
headings (see Fig. 2 for syntax). This resulted in 1161 citations. Inclusion
criteria were i) articles published between January 2000 and April 2023
ii) articles published in English iii) for primary research studies, the
mean age of subjects where stated was above 60 years. Studies exam­
ining vertebral osteoporosis were included if they recruited at least some
patients with vertebral fractures. However, articles that evaluated
Fig. 1. PRISMA flowchart.
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Injury 54 (2023) 110986
bracing in the context of peri‑operative intervention, kyphoplasty,
vertebroplasty and other indications unrelated to fractures, were
excluded. We excluded publications that considered taping and casting
as orthotic interventions. Two authors screened titles and abstracts,
distilling 176 citations that warranted full text evaluation. References
were searched and 2 additional studies were identified. 44 published
articles have been considered in this literature review [6–49].
These have been examined to appraise the impact of bracing on
spinal alignment, gait and postural stability, pain and functional well­
being, pulmonary function, bone density, compliance, adverse events
including delirium and cost-effectiveness.
S. Varma et al.
Fig. 2. Search syntax.
Results
Kyphotic deformity
2 studies demonstrated an increase in angle of kyphosis with use of
rigid and customized TLSOs in acute vertebral fractures [7,8]. However,
in the absence of a control arm, these findings are at best hypothesis
generating, as the effect of natural fracture ageing cannot be differen­
tiated from the impact of bracing.
Conversely, in sub-acute fractures, Pfeifer et al. demonstrated mean
reduction in angle of kyphosis by 7.9◦ in patients who wore semi-rigid
Spinomed orthosis and 8.1◦ in patients wearing spinomed active
orthosis (p<0.01) for 6 months [9]. In comparison, unbraced controls
had a mean reduction of 1.6◦ but upon cross over to intervention group,
a significant reduction in kyphotic angle was again observed after 6
months. One way crossover renders intention-to-treat analysis invalid
and the conclusion may be biased . Other studies did not show similar
results with bracing although this could also be attributable to chro­
nicity of fractures, different parameters to define kyphotic deformity
and a small sample size [10,11].
There are no studies that compare different types of orthoses on their
effect on kyphotic deformity.
Other radiological parameters of spinal deformity
Anterior vertebral body compression percentage (AVBCP) is the ratio
of the anterior vertebral height to the posterior aspect of the same
vertebra. Rigid bracing has shown a more favourable AVBCP compared
to soft bracing after 12 weeks of application (58.5 vs 54.6, p = 0.04), but
this difference did not reach statistical difference at 48 weeks [13].
Similarly, a small observational study showed beneficial reduction in
global sagittal alignment (48.3 + 7.64 vs 54.6 ± 8.49, p = 0.001) with
application of a semi-rigid orthosis after 6 weeks, but this rebounded to
baseline (52.60 + 9.84) at 6 months [14].
Only one study included an unbraced control group. It did not
demonstrate any difference in the anterior vertebral body height loss
between unbraced, soft-braced and rigid -braced groups after 12 weeks
(p = 0.237) [15].
Dynamic mobility is the difference in anterior vertebral height in
upright and supine positions. Its persistence may be prognostic of non-
union and pain [16]. TLSOs have been shown to successfully achieve
loss of dynamic mobility in 88.7%- 94% of patients at 6 months, but
causality cannot be inferred due to absence of non-intervention group
[7,12].
Postural stability & gait
Computed dynamic posturography in osteoporotic vertebral frac­
tures demonstrated improved average postural stability with Knight-
Taylor brace on (68.3 + 8.5% vs. 63.6 + 10.5%, p = 0.001), due to
beneficial influence on some metrics of static balance [17]. However,
the average directional control was reduced and on-axis velocity on
left/right rhythmic weight shift was higher, suggesting that bracing may
negatively impact dynamic balance.
Jacobs et al. demonstrated that wearing an orthosis decreases trunk
motion (2.38 cm+2.84 vs 3.60 cm+ 3.69 p = 0.006), allowing a more
upright posture [14]. It looked at the longitudinal effects of bracing on
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Injury 54 (2023) 110986
balance, demonstrating continued reduction in trunk motion by 8% at 6
weeks. The benefit was observed even when the brace was removed, but
diminished by 6 months. Observed benefits of bracing on walking speed,
stride length and cadence over 6 months cannot be differentiated from
the effect of natural fracture healing. There was no significant
improvement in the margin of stability [14].
Whether the indeterminate effects on static balance and stride
impact the overall risk of falls and physical activity in the acute phase
remains unevaluated.
Pain
TLSOs are commonly prescribed for pain management, to facilitate
early mobility and optimize functional performance. However, much of
the evidence base has emerged from observational data with no
unbraced comparison [7,13,14,18,19].
We identified four studies that compared orthosis groups to controls
[9,11,15,20].
Kaijser et al. showed no significant difference in visual analogue
scale (VAS) and Borg CR10 pain outcomes with orthosis application
when compared with unbraced controls or those prescribed exercise
training [11]. In contrast, a study showed that 6 months of Spinomed
reduced VAS by 37% (41±17.3 vs 65± 16.5, p = 0.001) from baseline
compared to non-intervention group (45± 16.5 vs 45±16.5) [20].
Pfeifer et al. demonstrated a statistically significant reduction in the
4-point Milner pain score in the braced group (− 1.5 ± 1.2, p < 0.02)
compared to the unbraced group (+0.1 ± 0.9), but treatment efficacy
remains dubious given the small change in pain reduction [9]. The
possibility of bias in using a subjective, uni-dimensional outcome mea­
sure needs to be considered [9,11,15,20]. Importantly, these studies did
not include acute fractures.
Kim et al. more robustly examined the use of opioids, alongside VAS
in acute single-level compression vertebral fractures, to conclude that
there was no difference in back pain at 3 months between the unbraced,
soft-braced and rigid-braced groups [15]. In fact, opioid use at 12 weeks
was lowest in the unbraced group (17.6%) compared to the soft-braced
(20%) or rigid-braced (23%) groups.
Other quality of life measures
Only two studies included unbraced comparison group. Pfeiffer et al.
demonstrated an improvement in Bergrow’s well-being score in non-
acute vertebral fractures treated with Spinomed (+10.4 ± 7.9,
p<0.01) and Spinomed active (+10.7 ± 8.2, p<0.01) but a decrease of
2.3 ± 3 in the unbraced group [9]. The same trend extended to LDL
disability and LDL self –care scores [9]. A study involving acute verte­
bral fractures contradicted these findings [15]. No-brace group was
non-inferior to soft and rigid braced groups in Oswestry Disability Index
(35.9 vs 37.8 vs 33.54, p = 0.260) and SF36 physical (p = 0.716) and
mental (p = 0.889) wellbeing assessments.
Qualitative data suggests that bracing contributes to a sense of sup­
port, security and improved ability to perform daily activities [18,21].
Studies have demonstrated better multi-dimensional functional
assessment scores with SDOs compared to rigid or semi-rigid braces [10,
12,22].
S. Varma et al.
Muscle strength
It has been postulated that the use of external support may exacer­
bate para-spinal atrophy. This has largely been extrapolated from
anthropometric indicators on healthy volunteers and we did not cite any
recent clinical studies to demonstrate that bracing adversely affects
para-spinal bulk in vertebral fractures [4,5,49].
SDOs have been shown to improve strength of spinal extensors and
abdominal flexors in vertebral fractures compared to controls [9,11,12,
19,20]. A randomized control trial showed a 29% increase in back
extensor strength with SDO compared to 9.9% without orthoses. How­
ever, the increase with exercise training alone was 22.1% and was not
statistically different compared to SDOs [11].
None of our included studies examined the effect of rigid or semi-
rigid TLSOs on spinal strength in an older patient cohort with acute
vertebral fractures.
Bone density
Bracing is thought to promote mechanical loading and osteogenesis.
Flexible orthosis in vertebral osteoporosis showed no change in bone
density after 10 weeks [18]. A weighted dynamic hyperextension brace
worn for 12 h a day in hyper-kyphotic osteoporotic post-menopausal
women was associated with a mean increase in bone mineral density
of 23.57 mg/cm2 compared to 7.04 mg/cm2 in the control group (p =
0.003) after 1 year [50]. Whether this translates into any sustained
reduction in vertebral fracture frequency is not known. In fact, a study
reported development of new fractures in 5.6% of patients when bracing
was applied to fresh vertebral fractures although causality cannot be
established in the absence of an unbraced control group [13].
Compliance
Only one study looked primarily at patient experiences, and reported
favourable adherence to dynamic orthosis due to perceived benefit in
maintaining good posture and improving muscle strength [21]. Another
study reported compliance of 66% at 6 months [20].
Drop out rates in trials could be auxillary indicators of compliance –
in one study, only 5 out of 92 patients in the orthoses groups dropped
out, and in fact most continued with the treatment beyond the intended
intervention period [9]. Another large multi-centre study showed that
dropout rates were 9.3% with customized rigid TLSOs, 10.8% with
customized elastic braces and 9.7% with ready- made elastic braces
[25].
Stated reasons for poor compliance include worsening back pain,
difficulty putting the orthosis on and interference with urinary voiding
[8,19,20].
Adverse effects
Numerous complications associated with spinal bracing have been
reported including pulmonary infections, decubitus ulcers, cutaneous
reactions, re-fractures, urinary tract infections, gastric ulcers, ileus and
inguinal hernia [7,12,13,26,27]. The frequency of these cannot be
ascertained. In the absence of controlled studies, causation is difficult to
establish and none of our identified studies looked at mortality as an
outcome measure.
While 2 studies have shown no difference in the types of brace and
tolerability, a meta-analysis concluded that complications were highest
with rigid TLSOs [4,28,29].
Cognition
Delirium is one of the most commonly encountered complications in
older patients with vertebral fractures [30]. It has been postulated that
post-operative delirium in elective spinal surgery may be reduced by
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Injury 54 (2023) 110986
orthoses by facilitating early ambulation [51]. However, in clinical
practice, cognitive impairment is an important barrier to brace
compliance. It is also known that physical restraints are associated with
development of delirium. None of the studies we identified examined
the association of bracing and cognitive outcomes.
One study has demonstrated that there was no association between
the type of brace and the mini-mental state examination at 6 months
[25].
Pulmonary function
Studies in juvenile kypho-scoliosis suggest that bracing may reduce
pulmonary function due to restrictive effects on the thoracic cage [52,
53]. Ageing is associated with reduction in lung compliance, forced
expiratory volume in 1 second (FEV1) and diaphragmatic muscle
strength. Osteoporotic vertebral fractures themselves are associated
with a two-fold increase in mortality due to pulmonary complications
[54].
3-point brace immobilization in acute fractures for two and a half
months was associated with a reduction in average FEV1 from 67.8% at
7 days to 59.6% at 3 months [12]. FEV1 in SDO patients was 66.9% at 7
days and 57.3% at 3 months [12]. In contrast, SDO in sub-acute fractures
was associated with an increase in relaxed vital capacity (+6.1 ± 20.5%
vs. − 9.9 ± 16.1% in unbraced controls) and FEV1 (+2.1 ± 13.5% vs.
− 3.8 ± 16.1% in unbraced controls) and the differences were statisti­
cally significant [6]. The differences in the findings of the 2 studies could
be explained by the age of the fractures but also the treatment effect of
kyphotic correction on respiratory function, as the latter study demon­
strated significant improvement in kyphosis with bracing.
Cost effectiveness
The cost of a brace is estimated to be £150–220 in our National
Health Services Trust, although the costs will vary in different health­
care settings [35]. Moreover, customization of TLSOs requires orthotic
input and can take 24 to 72 h to order, which adds to bed days (esti­
mated £500–800/day) and delayed ambulation [28]. Delayed ambula­
tion in older patients may contribute to burden of morbidity and further
prolongation of in-hospital stay.
A recent meta-analysis with mean age of 39–47 years concluded that
bracing increased the average length of stay by 3.47 days [36]. This is
probably higher in older cohorts, although no studies have looked at
patient flow and health-care costs.
Discussion
Our literature search included twenty-four primary studies - only six
of these had an unbraced control arm [6,9,11,15,17,25]. Only ten
studies looked at acute onset fractures, mostly osteoporotic compression
fractures. Only two studies in our literature search included burst frac­
tures that are associated with higher mechanism of injury and greater
morphological disruption [8,28]. There was considerable heterogeneity
in bracing conditions and outcome measures. Consequently, as evidence
quality is poor, it is difficult to make any robust conclusions. There is
significant selection bias, and many studies cannot be applied to the frail
older trauma population that present to hospital. Most studies excluded
subjects that were non-ambulatory, had other concurrent common spi­
nal pathologies such as stenosis and arthritides or had cognitive
impairment. None of the studies looked at fractures with suspected
ligamentous or neurological instability. The role of bracing in older
patients with non-operatively managed types B and C sub-classification
of thoracolumbar fractures is beyond the scope of this review, but a
commonplace scenario void of scientific data.
Crucially, there is no evidence that use of rigid or semi-rigid TLSOs in
acute vertebral fractures improves truncal strength, kyphotic deformity,
pain or quality of life. There is weak evidence to suggest that compared
S. Varma et al.
to soft braces, rigid and semi-rigid braces may benefit posture, initial
vertebral body height and global sagittal alignment [13,14]. However,
these effects are only transient and no long-lasting difference has been
observed [8,12-15]. With no conclusive evidence supporting
longer-term effectiveness or utility of bracing in acute vertebral frac­
tures, cost effectiveness and any associated complications cannot be
justified [36].
Intriguingly, there is emerging data on the use of SDOs in manage­
ment of sub-acute fractures. SDOs provide biofeedback stimulation to
spinal musculature. They may improve spinal strength although not to
any greater advantage than routine physical therapy. There is some
evidence on favourable impact on spinal curvature, pain and quality of
life. Further research is required on biomechanical parameters and pa­
tient characteristics most likely to benefit from SDOs in sub-acute stages
of fracture healing.
Data reports favourable compliance to TLSOs, which is in stark
contrast to clinical experience where many older adults do not tolerate
spinal bracing, often due to pain or cognitive barriers. Even in the
absence of robust objective benefits, patients’ subjective perception of
bracing and assessment of patient-reported outcomes should be regar­
ded - if it affords psychological wellbeing, it may positively influence
everyday activities [6,9,18,21]. Compliance is likely over-estimated as
research populations are not reflective of the multi-morbid and frailer
population of patients in hospital, admitted with acute traumatic
injuries.
TLSOs are not without adverse effects and contribute to bed days and
healthcare costs, although no studies have been dedicated to quantify
these important outcomes in older patients.
Conclusion
There is no evidence for rigid or semi-rigid immobilization of stable
acute thoracolumbar fractures. Literature overlooks many important
challenges in older patients that need to be factored in the decision-
making paradigm.
This review incentivizes urgent deliberation of standard practice and
stepping away from habitual prescription of TLSOs. To evolve TLSO
pathways in older populations, there is a need for robust randomized
controlled trials, but also for real world evidence representing the frailer
in-patient population, with emphasis on outcomes such as compliance,
delirium, costs, mortality and patient-reported outcome measures. In the
meanwhile, national and international consensus guidelines are needed
to dissuade undifferentiated use of TLSOs.
The role of spinal orthoses however is not redundant. SDOs may offer
scope in rehabilitative medicine for individual patients at risk of longer-
term pain and deformity from spinal fractures.
Declaration of Competing Interest
None.
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