Long Term Lumbosacral Bracing and Its Adverse Effects on Low Back

Introduction

Low back pain (LBP) is the most weakening condition and disc degeneration has been noted to be its significant risk factor.¹ Chronic low back pain (CLBP) is defined “ as the pain or stiffness, localized below the costal margins and above the inferior gluteal folds, which may be accompanied with sciatica and persist for ≥ 12 weeks.” The pain with the same location and characteristics, when lasting for duration of 6–12 weeks is called as sub-acute low back pain (SLBP). Most of these patients present with non-specific and gradually progressive back pain.² It is highly prevalent and a major health burden globally as well as in India. Such patients are considered to be at high risk for developing the complications of untreated vitamin D deficiency.²

Sedentary lifestyle, overweight and low back pain are generally assumed to be related. Low back pain is found to be the most debilitating condition leading to low level of quality of life (QOL) and disability among women with low back pain.³ This has a huge economic burden on people for its treatment. Low back pain is usually treated conservatively through medications, physiotherapy and in severe cases through surgeries.

Usually it has been seen that in chronic cases of low back pain, patients get used to wearing lumbar corset or brace or belt on long term basis which can have a lot of adverse effect on their back. The spine is supported from outside by the use of braces or corsets which usually fit snuggly to the lumbar region in a circumferential manner. These are the simplest forms of supportive braces.⁴ Lumbar corset or lumbosacral belts should not be worn for more than six weeks and weaning off after three weeks should be done according to the pain and discomfort levels. Continuous use of these lumbar braces leads to gross limitation of lumbar range of motion such as lumbar extension, flexion and lateral bending.⁵ This leads to further deterioration of patients’ symptoms thereby causing long term psychological dependency on those braces to carry out their daily activities. This dependency on the braces and the restrictions in the lumbar Range of Motion (ROM) in turn causes the soft tissues of the region to shorten, adapt and restrict the motion further in the spinal segments.

Case Presentation

A 63-year-old female presented with disabling low back pain that inhibited her from bending forwards and backwards. She gave a history of first episode of the pain 18 years back which was managed with home remedies and then had frequent similar episodes for few years. In 2014, she consulted an Orthopedic surgeon for the same and was prescribed physiotherapy, medications and lumbosacral belt as her X-ray examination showed L3- L4, L5-S1 spondylitic changes. After that, she continued to take physical therapy (electrotherapy to be precise) sessions often and continued the use of lumbosacral belt while avoiding forward and backward bending fearing pain and worsening of the condition. Moreover, she was diagnosed with Myasthenia Gravis two years back in 2018 for which she is presently on medications and had undergone thymectomy in 2019.

On physical examination, Straight Leg Raise- SLR Test was negative. Her pain intensity on Visual Analog Scale (VAS) was 8/10. Her lumbar range of movement was grossly limited as she could not bend forward, backward or sideways while standing and on sitting. Her score on Oswestry Low Back Pain Disability Questionnaire was 52% and on Fear Avoidance Beliefs questionnaire (FABQ) was 64.5%. Her area of pain was around the level of L4-L5 (Figure 1). She complained of continuous pain throughout the day that increased on sitting and walking and was relieved on lying down. Range of trunk forward flexion was measured using Schober’s test (Figure 2) and the difference was less than 1cm.

Positive Schober’s test – Less than 5 cm increase in length with forward flexion is considered as decreased lumbar spine range of motion. Technique- While the patient is standing, examiner marks the L5 spinous process by drawing a horizontal line across the patient’s back. A second line is marked 10 cm above the first line. Patient is then instructed to flex forward as if attempting to touch his/her toes. Examiner re-measures distance between two lines with patient fully flexed. The difference between the measurements in erect and flexion position indicates the outcome of lumbar flexion. (Figure 2).

The patient was treated in our physical therapy department with Ultrasound (UST) for 5 minutes in continuous mode with 1MHz transducer head followed by 10 minutes of Interferential Current Therapy (IFT) over lower back region. 6,7,8 Ultrasound therapy refers to use of ultrasound which are mechanical vibrations that are essentially the same as sound waves but of higher frequency. These are travelling pressure waves in the medium which causes an alternate compression and rarefaction of particles, therefore it is the only form of wave which moves forward the actual particles, merely vibrate back and forth each about mean point. This further helps to reduce edema and its mechanical effect helps in reducing pain. IFT uses a medium frequency current widely used for pain control. Two medium frequency currents are passed simultaneously through the surface area and interfere with each other. This interaction has characteristics of low frequency stimulation. The principle of reduction in pain is because of gate control theory and stimulated release of pain reducing substances endorphin and encephalin.

Apart from this, the patient was taught forward-bending exercise in sitting position to stretch the back muscles and other back mobility exercises to be done at home (10 reps each of three sets) along with back muscle isometrics using the wall.⁹ Along with this, she was educated about the anatomy of the lumbar region, its mobility and the adverse effects of not moving the lower back regularly and the detrimental effects of wearing the belts over prolonged periods. The patient was able to clear both her scapulae off the plinth with the hands on the side while assessing the strength of abdominal muscles indicating Grade 3 on Manual Muscle Testing (MMT) scale on the last day of the treatment session. A graded abdominal muscle strengthening protocol handout (with pictures) was given to her to continue at home for 4-6 weeks and a review was scheduled after that. She and her relatives were taught how to wean-off lumbosacral belt for few hours a day initially and then gradually quit the usage completely by the end of four weeks.

The electrotherapy was given for seven sessions in our Physiotherapy Department with periodic assessment as mentioned in Table 1.

After seven days of treatment, her VAS score had come down to 3/10 and Oswestry Low Back Pain Disability Questionnaire score had come to 44% and FABQ score was 31.2%. Her mobility in the lumbar region improved and her dependency on the belt reduced gradually.

Discussion

Continuous use of lumbar braces leads to gross limitation of lumbar range of motion such as lumbar extension, flexion and lateral bending.⁵ This leads to further deterioration of patient symptoms thereby causing long term psychological dependency on those braces to carry out their daily activities. This dependency on the braces and the restrictions in the lumbar ROM in turn causes the soft tissues of the region to shorten, adapt and restrict the motion further in the spinal segments. In this study, we found that back mobility exercises are the key to improve chronic back pain. Rainville et al., (1997) had highlighted the importance of strengthening, especially of the lumbar spine extensors in CLBP patients and had also emphasized on abdominal strengthening to facilitate trunk stabilization. Hitherto, we could learn that lumbar corsets/ lumbosacral belts usage for prolonged duration could lead to high degree of dependency and restricted range of motion leading to non-relieving chronic low back pain. Results on the outcome measures would have been much higher, had it been more number of physiotherapy sessions and meticulous compliance in performing home exercise program for a longer period. We hereby conclude that prolonged use of lumbar corsets/ lumbosacral belts leads to lumbar immobility which further leads to weakness of back and core muscles. Educating the patient regarding the same and emphasizing more on lumbar mobility exercises on a regular basis can improve the range of motion, reduce pain along with decrease in fear avoidance behavior.